1649833062 NPI number — ILLUMINATE KETAMINE CENTER PLLC

Table of content: (NPI 1649833062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649833062 NPI number — ILLUMINATE KETAMINE CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLUMINATE KETAMINE CENTER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ILLUMINATE WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649833062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1936 BROOKSIDE DR STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-765-0777
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1936 BROOKSIDE DR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-765-0777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BEASLEY
Authorized Official First Name:
SHELIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER/ PRESIDENT
Authorized Official Telephone Number:
423-765-0777

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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