Organization
REVIVE KETAMINE AND WELLNESS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. NICHOLAS GEORGE SANSONE (DR)
(773) 208-5872
Entity
Organization
Contact information
Practice address
210 MEIJER DR STE C, LAFAYETTE, IN 47905-4694
(765) 764-9305
Mailing address
3040 LAKE SHORE DR, MICHIGAN CITY, IN 46360-1708
(773) 208-5872
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
—
—
Other
Enumeration date
03/09/2026
Last updated
03/09/2026
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