Provider Demographics
NPI:1316577679
Name:IGNITE MEDICAL RESORT OKC, LLC
Entity Type:Organization
Organization Name:IGNITE MEDICAL RESORT OKC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:JARET
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-324-7993
Mailing Address - Street 1:1550 N NORTHWEST HWY STE 430
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6312 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1463
Practice Address - Country:US
Practice Address - Phone:405-946-6932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility