Healthcare Provider Details

I. General information

NPI: 1992575682
Provider Name (Legal Business Name): VIVIDLIFE KETAMINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5167 CLAYTON RD STE H
CONCORD CA
94521-3170
US

IV. Provider business mailing address

5167 CLAYTON RD STE H
CONCORD CA
94521-3170
US

V. Phone/Fax

Practice location:
  • Phone: 323-336-1178
  • Fax:
Mailing address:
  • Phone: 925-489-2984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BE-VERLYN NAVARRO
Title or Position: NP
Credential:
Phone: 323-336-1178