MEDICARE: TREASURE COAST KETAMINE WELLNESS & IV NUTRITION CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WI0500X	Infusion Therapy Registered Nurse
2	261QI0500X	Infusion Therapy Clinic/Center

General Provider Information

NPI Number	:	1801408208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREASURE COAST KETAMINE WELLNESS & IV NUTRITION CENTER

Provider Business Mailing Address
First Line	:	787 37TH ST STE E110
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-7319
Country	:	US
Telephone Number	:	772-907-5917
Fax Number	:	772-907-5917

Provider Business Practice Location Address
First Line	:	787 37TH ST STE E110
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-7319
Country	:	US
Telephone Number	:	772-907-5917
Fax Number	:	772-907-5917

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY JARRELL MCCRACKEN
Credential	:	CRNA
Telephone Number	:	352-262-8439

Provider Enumeration Date	:	08/18/2020
Last Update Date	:	06/01/2026

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