MEDICARE: REVIVE KETAMINE AND WELLNESS PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1841146214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE KETAMINE AND WELLNESS PC

Provider Business Mailing Address
First Line	:	3040 LAKE SHORE DR
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-1708
Country	:	US
Telephone Number	:	773-208-5872
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 MEIJER DR STE C
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-4694
Country	:	US
Telephone Number	:	765-764-9305
Fax Number	:

Authorized Official
Title or Position	:	DR
Name	:	DR. NICHOLAS GEORGE SANSONE
Credential	:
Telephone Number	:	773-208-5872

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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