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NPI Code Detail

MEDICARE: IGNITE TEEN TREATMENT, LLC

MEDICARE: IGNITE TEEN TREATMENT, LLC
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
1261QM0855XAdolescent and Children Mental Health Clinic/Center
2324500000XSubstance Abuse Rehabilitation Facility
3323P00000XPsychiatric Residential Treatment Facility

General Provider Information

NPI Number : 1346751526
Entity Type Code : Organization
Provider Name (Legal Business Name) : IGNITE TEEN TREATMENT, LLC
Provider Business Mailing Address
First Line : 512 NORTHAMPTON ST # 158
Second Line :
City : EDWARDSVILLE
State : PA
Zip : 18704-4560
Country : US
Telephone Number : 570-203-9222
Fax Number : 570-203-9477
Provider Business Practice Location Address
First Line : 3722 LONE MESA DR
Second Line :
City : LAS VEGAS
State : NV
Zip : 89147
Country : US
Telephone Number : 310-721-6447
Fax Number :
Authorized Official
Title or Position : CFO
Name : ALAN BOND
Credential :
Telephone Number : 570-203-9222
Provider Enumeration Date : 10/16/2017
Last Update Date : 11/20/2023

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Directions to “IGNITE TEEN TREATMENT, LLC ” Practice Location

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