Provider Demographics
NPI:1184305666
Name:IGNITE CLINICAL WELLNESS GROUP
Entity type:Organization
Organization Name:IGNITE CLINICAL WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:O
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-859-2071
Mailing Address - Street 1:5600 GOODMAN RD STE G
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-985-4101
Mailing Address - Fax:662-404-7288
Practice Address - Street 1:5600 GOODMAN RD STE G
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:662-985-4101
Practice Address - Fax:662-404-7288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty