Innerbloom Ketamine Therapy

Primary specialty

Integrative Medicine PhysicianTaxonomy code 202D00000X

Legal business name

INNERBLOOM KETAMINE THERAPY

Practice address

100 Casa St Ste D3
San Luis Obispo, CA 93405-5827

Phone

(805) 321-8471

Fax

(805) 567-6604

NPI assigned

Dec 9, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ray Rivas, MDNPI 1003173816

Title

MD

Phone

(805) 321-8471

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Ray Herman Rivas, M.D.

  • Psychiatry Physician
  • San Luis Obispo, CA
  • NPI 1003173816

  Single Specialty

  Medicare reassignment NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1733702400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1772496000000",
    "number": "1184430696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CASA ST STE D3",
            "city": "SAN LUIS OBISPO",
            "state": "CA",
            "postal_code": "934055827",
            "telephone_number": "805-321-8471",
            "fax_number": "805-567-6604"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 CASA ST STE D3",
            "city": "SAN LUIS OBISPO",
            "state": "CA",
            "postal_code": "934055827",
            "telephone_number": "805-321-8471",
            "fax_number": "805-567-6604"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNERBLOOM KETAMINE THERAPY",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-12-09",
        "last_updated": "2026-03-03",
        "certification_date": "2026-03-03",
        "status": "A",
        "authorized_official_last_name": "RIVAS",
        "authorized_official_first_name": "RAY",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "805-321-8471",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "202D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Integrative Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Integrative Medicine Physician in San Luis Obispo, CA
• Providers in San Luis Obispo, CA by specialty
• Integrative Medicine Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.