Provider Demographics
NPI:1629452149
Name:IGNITE SPORTS AND REHAB OF ARDMORE INC
Entity Type:Organization
Organization Name:IGNITE SPORTS AND REHAB OF ARDMORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:TREADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-490-3312
Mailing Address - Street 1:908 N ROCKFORD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2540
Mailing Address - Country:US
Mailing Address - Phone:580-490-3312
Mailing Address - Fax:580-490-3318
Practice Address - Street 1:908 N ROCKFORD RD
Practice Address - Street 2:SUITE C
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2540
Practice Address - Country:US
Practice Address - Phone:580-490-3312
Practice Address - Fax:580-490-3318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45552251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty