Healthcare Provider Details

I. General information

NPI: 1366077539
Provider Name (Legal Business Name): SCENIC CITY NEUROTHERAPY AND KETAMINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 11/29/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7405 SHALLOWFORD RD STE 240
CHATTANOOGA TN
37421-2662
US

IV. Provider business mailing address

7405 SHALLOWFORD RD STE 240
CHATTANOOGA TN
37421-2662
US

V. Phone/Fax

Practice location:
  • Phone: 423-228-0579
  • Fax:
Mailing address:
  • Phone: 423-228-0579
  • Fax: 423-702-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES BRIAN MILLER
Title or Position: CMO
Credential: CRNA
Phone: 423-290-2411