MEDICARE: REVITALIST

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	103T00000X	Psychologist
4	103TC1900X	Counseling Psychologist
5	261QI0500X	Infusion Therapy Clinic/Center
6	261QM1300X	Multi-Specialty Clinic/Center
7	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073168241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVITALIST

Provider Business Mailing Address
First Line	:	10608 FLICKENGER LN
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37922-3485
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10608 FLICKENGER LN
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37922-3485
Country	:	US
Telephone Number	:	865-392-6262
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL EMPLOYEE
Name	:	KATHRYN WALKER
Credential	:	CRNA
Telephone Number	:	865-392-6262

Provider Enumeration Date	:	08/05/2019
Last Update Date	:	03/07/2025

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