Healthcare Provider Details

I. General information

NPI: 1629452149
Provider Name (Legal Business Name): IGNITE SPORTS AND REHAB OF ARDMORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N ROCKFORD RD SUITE C
ARDMORE OK
73401-2540
US

IV. Provider business mailing address

908 N ROCKFORD RD SUITE C
ARDMORE OK
73401-2540
US

V. Phone/Fax

Practice location:
  • Phone: 580-490-3312
  • Fax: 580-490-3318
Mailing address:
  • Phone: 580-490-3312
  • Fax: 580-490-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number4555
License Number StateOK

VIII. Authorized Official

Name: BRIAN MARK TREADWELL
Title or Position: CEO / OWNER
Credential:
Phone: 580-490-3312