Healthcare Provider Details

I. General information

NPI: 1932899689
Provider Name (Legal Business Name): IGNITE MEDICAL HANOVER PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W LAKE ST
HANOVER PARK IL
60133-4302
US

IV. Provider business mailing address

1550 N NORTHWEST HWY STE 430
PARK RIDGE IL
60068-1461
US

V. Phone/Fax

Practice location:
  • Phone: 630-556-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY FIELDS
Title or Position: MANAGER
Credential:
Phone: 833-944-6483