Provider Demographics
NPI:1366077539
Name:SCENIC CITY NEUROTHERAPY AND KETAMINE CENTER LLC
Entity type:Organization
Organization Name:SCENIC CITY NEUROTHERAPY AND KETAMINE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:423-290-2411
Mailing Address - Street 1:7405 SHALLOWFORD RD STE 240
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2662
Mailing Address - Country:US
Mailing Address - Phone:423-228-0579
Mailing Address - Fax:423-702-6025
Practice Address - Street 1:7405 SHALLOWFORD RD STE 240
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2662
Practice Address - Country:US
Practice Address - Phone:423-228-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty