Healthcare Provider Details

I. General information

NPI: 1043616840
Provider Name (Legal Business Name): IGNITE LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 N 1ST ST
SPRINGFIELD NE
68059-4704
US

IV. Provider business mailing address

780 N 1ST ST
SPRINGFIELD NE
68059
US

V. Phone/Fax

Practice location:
  • Phone: 402-915-1559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-66768
License Number StateNE

VIII. Authorized Official

Name: MRS. ASHLIE BERGREN
Title or Position: OWNER/IBCLC
Credential: RN BSN IBCLC
Phone: 402-915-1559