Basic Information
| Provider Information | |||||||||
| NPI: | 1912500158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IGNITE MEDICAL RESORT CARONDELET, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 N NORTHWEST HWY STE 430 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681461 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 CARONDELET DR | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641144670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169411300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | FIELDS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8339446483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.