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General NPI Number Information
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NPI Number | 1841146214
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Entity Type | Organization
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Legal Business Name | REVIVE KETAMINE AND WELLNESS PC
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Dates
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Enumeration Date | 03/09/2026
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Last Update Date | 03/09/2026
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Provider Practice Location Address
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Address Line | 210 MEIJER DR STE C
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City | LAFAYETTE
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State | IN
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Zip | 47905-4694
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Country | US
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Telephone | 765-764-9305
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Fax |
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Provider Business Mailing Address
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Address Line | 3040 LAKE SHORE DR
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-1708
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Country | US
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Telephone | 773-208-5872
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Fax |
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Authorized Official
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Title or Position | DR
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Name | DR. NICHOLAS GEORGE SANSONE
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Credential |
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Telephone | 773-208-5872
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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