Healthcare Provider Details

I. General information

NPI: 1629609441
Provider Name (Legal Business Name): IGNITE TEEN TREATMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 PASEO DEL PRADO STE C101
LAS VEGAS NV
89102-4336
US

IV. Provider business mailing address

8635 W SAHARA AVE # 10
LAS VEGAS NV
89117-5858
US

V. Phone/Fax

Practice location:
  • Phone: 725-272-0330
  • Fax:
Mailing address:
  • Phone: 725-272-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

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