MEDICARE: IGNITE RUN COLLECTIVE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1285422741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IGNITE RUN COLLECTIVE, LLC

Provider Business Mailing Address
First Line	:	270 LAWRENCE PL
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-1068
Country	:	US
Telephone Number	:	678-523-0452
Fax Number	:

Provider Business Practice Location Address
First Line	:	5829 CAMPBELLTON RD SW STE 102
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-8036
Country	:	US
Telephone Number	:	404-205-5877
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICKEY ROSS
Credential	:
Telephone Number	:	678-523-0452

Provider Enumeration Date	:	04/25/2025
Last Update Date	:	04/25/2025

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