Provider Demographics
NPI:1407346158
Name:IGNITE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:IGNITE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:PTA,KTS
Authorized Official - Phone:860-912-6118
Mailing Address - Street 1:1805 RUBEN TORRES SR BLVD STE B5
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-1113
Mailing Address - Country:US
Mailing Address - Phone:830-513-4104
Mailing Address - Fax:
Practice Address - Street 1:1805 RUBEN TORRES BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526
Practice Address - Country:US
Practice Address - Phone:830-513-4104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730397928Medicaid
TX1942731625Medicaid