Provider Demographics
NPI:1053984484
Name:REVIVE KETAMINE CLINIC, PLLC
Entity type:Organization
Organization Name:REVIVE KETAMINE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CRNA
Authorized Official - Phone:901-317-7900
Mailing Address - Street 1:5820 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-4518
Mailing Address - Country:US
Mailing Address - Phone:901-317-7900
Mailing Address - Fax:901-317-7899
Practice Address - Street 1:5820 STAGE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4518
Practice Address - Country:US
Practice Address - Phone:901-317-7900
Practice Address - Fax:901-317-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty