=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790576577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREAMSCAPE KETAMINE AND IV THERAPY LOUNGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3530 CAMINO DEL RIO N STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-992-9778
-----------------------------------------------------
Fax | 619-374-1696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3530 CAMINO DEL RIO N STE 200
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-992-9778
-----------------------------------------------------
Fax | 619-374-1696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | SHERRY ANN SMITH
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 619-762-8902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SP0812X
-----------------------------------------------------
Taxonomy Name | Community Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------