MEDICARE: IGNITE PHYZIO & SPORTS PERFORMANCE INC

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	261QP2000X	Physical Therapy Clinic/Center	PT37147	CA

General Provider Information

NPI Number	:	1306354881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IGNITE PHYZIO & SPORTS PERFORMANCE INC

Provider Business Mailing Address
First Line	:	1703 SHADY BROOK DR
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92831-1850
Country	:	US
Telephone Number	:	562-896-0129
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 E LAMBERT RD
Second Line	:
City	:	LA HABRA
State	:	CA
Zip	:	90631-6143
Country	:	US
Telephone Number	:	562-896-0129
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ZIAD DAHDUL
Credential	:	PT
Telephone Number	:	562-896-0129

Provider Enumeration Date	:	01/18/2018
Last Update Date	:	03/09/2020

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