Provider Demographics
NPI:1790576577
Name:DREAMSCAPE KETAMINE AND IV THERAPY LOUNGE
Entity type:Organization
Organization Name:DREAMSCAPE KETAMINE AND IV THERAPY LOUNGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:619-762-8902
Mailing Address - Street 1:3530 CAMINO DEL RIO N STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1745
Mailing Address - Country:US
Mailing Address - Phone:619-992-9778
Mailing Address - Fax:619-374-1696
Practice Address - Street 1:3530 CAMINO DEL RIO N STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1745
Practice Address - Country:US
Practice Address - Phone:619-992-9778
Practice Address - Fax:619-374-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community