Healthcare Provider Details

I. General information

NPI: 1053984484
Provider Name (Legal Business Name): REVIVE KETAMINE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 STAGE RD
BARTLETT TN
38134-4518
US

IV. Provider business mailing address

5820 STAGE RD
BARTLETT TN
38134-4518
US

V. Phone/Fax

Practice location:
  • Phone: 901-317-7900
  • Fax: 901-317-7899
Mailing address:
  • Phone: 901-317-7900
  • Fax: 901-317-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. GINGER WILLIAMS
Title or Position: OWNER/PRACTITIONER
Credential: DNP, CRNA
Phone: 901-317-7900