REVIVE KETAMINE CLINIC PLLC NPI 1053984484

NPI Information

  • NPI: 1053984484
  • Provider Name: REVIVE KETAMINE CLINIC, PLLC
  • Classification: Clinic/Center - 261QM2500X
  • Specialization: Medical Specialty
  • Entity Type: Organization
  • CLIA Number: 44D2186319
  • Address: 5820 STAGE RD
    BARTLETT, TN
    ZIP 38134
  • Phone: (901) 317-7900

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NPI Details

REVIVE KETAMINE CLINIC, PLLC is a medical specialty clinic center in Bartlett, TN. The provider is an entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to a specific area of medical specialization. Frequently used for Title V related Children's Specialty services or to meet specific public health needs (e.g., infectious diseases or breast and cervical cancer). REVIVE KETAMINE CLINIC, PLLC NPI is 1053984484. The provider is registered as an organization entity type.

The provider's business location address is:

5820 STAGE RD
BARTLETT, TN
ZIP 38134-518
Phone: (901) 317-7900
Fax: (901) 317-7899

The provider's authorized official is Ginger Williams .
The authorized official title is Owner/practitioner and has the following contact phone number (901) 317-7900.

The CLIA number assigned to this NPI record is 44D2186319 - other - infusion clinic with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 7/22/2021 and was last updated on 4/15/2024.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1261QM2500XClinic/CenterMedical SpecialtyYes
2363LP0808XNurse PractitionerPsychiatric/Mental HealthNo

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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