Healthcare Provider Details

I. General information

NPI: 1285964932
Provider Name (Legal Business Name): ICE20 - TRIAD SPORTS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 CALLE QUETZAL
CAMARILLO CA
93012-8558
US

IV. Provider business mailing address

4690 CALLE QUETZAL
CAMARILLO CA
93012-8558
US

V. Phone/Fax

Practice location:
  • Phone: 805-857-4172
  • Fax:
Mailing address:
  • Phone: 805-857-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BRAD L SMITH
Title or Position: DIVISION PRESIDENT
Credential:
Phone: 805-857-4172