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General NPI Number Information
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NPI Number | 1629452149
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Entity Type | Organization
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Legal Business Name | IGNITE SPORTS AND REHAB OF ARDMORE INC
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Dates
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Enumeration Date | 07/14/2015
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Last Update Date | 07/14/2015
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Provider Practice Location Address
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Address Line | 908 N ROCKFORD RD SUITE C
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City | ARDMORE
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State | OK
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Zip | 73401-2540
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Country | US
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Telephone | 580-490-3312
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Fax | 580-490-3318
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Provider Business Mailing Address
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Address Line | 908 N ROCKFORD RD SUITE C
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City | ARDMORE
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State | OK
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Zip | 73401-2540
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Country | US
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Telephone | 580-490-3312
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Fax | 580-490-3318
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Authorized Official
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Title or Position | CEO / OWNER
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Name | BRIAN MARK TREADWELL
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Credential |
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Telephone | 580-490-3312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 4555
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License Number State | OK
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