MEDICARE: IGNITE TEEN TREATMENT, 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	324500000X	Substance Abuse Rehabilitation Facility
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1629609441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IGNITE TEEN TREATMENT, LLC

Provider Business Mailing Address
First Line	:	8635 W SAHARA AVE # 10
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5858
Country	:	US
Telephone Number	:	725-272-0330
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 PASEO DEL PRADO STE C101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4336
Country	:	US
Telephone Number	:	725-272-0330
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ALAN BOND
Credential	:
Telephone Number	:	310-774-1303

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	05/09/2023

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