Provider Demographics
NPI:1346751526
Name:IGNITE TEEN TREATMENT, LLC
Entity Type:Organization
Organization Name:IGNITE TEEN TREATMENT, LLC
Other - Org Name:IGNITE TEEN TREATMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-203-9222
Mailing Address - Street 1:512 NORTHAMPTON ST # 158
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4560
Mailing Address - Country:US
Mailing Address - Phone:570-203-9222
Mailing Address - Fax:570-203-9477
Practice Address - Street 1:3722 LONE MESA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:310-721-6447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility