NPIMap

Organization Active NPI

Pride Medical Spa and Wellness Center Inc

Doing business as Radiance Ketamine Clinic

  • Psychiatry Physician
  • Reno, NV
National Provider Identifier
1912543968
Registry record updated Aug 27, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PRIDE MEDICAL SPA AND WELLNESS CENTER INC
Doing business as
Radiance Ketamine Clinic
Practice address
5365 Mae Anne Ave Ste A10
Reno, NV 89523-1841
Phone
(775) 432-1500
Fax
(775) 432-1002
NPI assigned
Nov 25, 2019
Last updated
Aug 27, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 27, 2020

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

Authorized official

Name
Mr. Greg Jones, CRNA, MS, BSN
Title
Clinic Director
Phone
(775) 217-0332

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

5365 Mae Anne Ave Ste A10
Reno, NV 89523-1841

Mailing address

5365 Mae Anne Ave Ste A10
Reno, NV 89523-1841
Phone (775) 432-1500

Other names 1

  • Radiance Ketamine Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Pride Medical Spa and Wellness Center Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

5365 Mae Anne Ave
Ste A10
Reno, NV 89523
Phone (775) 432-1500

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1574640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598486400000",
    "number": "1912543968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5365 MAE ANNE AVE STE A10",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895231841",
            "telephone_number": "775-432-1500",
            "fax_number": "775-432-1002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5365 MAE ANNE AVE STE A10",
            "city": "RENO",
            "state": "NV",
            "postal_code": "895231841",
            "telephone_number": "775-432-1500",
            "fax_number": "775-432-1002"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIDE MEDICAL SPA AND WELLNESS CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-11-25",
        "last_updated": "2020-08-27",
        "certification_date": "2020-08-27",
        "status": "A",
        "authorized_official_last_name": "JONES",
        "authorized_official_first_name": "GREG",
        "authorized_official_title_or_position": "CLINIC DIRECTOR",
        "authorized_official_telephone_number": "775-217-0332",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CRNA, MS, BSN"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Radiance Ketamine Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Radiance Ketamine Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Reno, NV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.