Healthcare Provider Details

I. General information

NPI: 1477217784
Provider Name (Legal Business Name): IGNITE TEEN TREATMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 DAVIDSON AVE STE 105
SOMERSET NJ
08873-4141
US

IV. Provider business mailing address

270 PIERCE ST STE 208
KINGSTON PA
18704-5141
US

V. Phone/Fax

Practice location:
  • Phone: 570-203-9222
  • Fax: 570-203-9477
Mailing address:
  • Phone: 570-203-9222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALAN BOND
Title or Position: CFO
Credential:
Phone: 310-774-1303