Healthcare Provider Details

I. General information

NPI: 1790576577
Provider Name (Legal Business Name): DREAMSCAPE KETAMINE AND IV THERAPY LOUNGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 CAMINO DEL RIO N STE 200
SAN DIEGO CA
92108-1745
US

IV. Provider business mailing address

3530 CAMINO DEL RIO N STE 200
SAN DIEGO CA
92108-1745
US

V. Phone/Fax

Practice location:
  • Phone: 619-992-9778
  • Fax: 619-374-1696
Mailing address:
  • Phone: 619-992-9778
  • Fax: 619-374-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0812X
TaxonomyCommunity Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: SHERRY ANN SMITH
Title or Position: COO
Credential: RN
Phone: 619-762-8902