Provider Demographics
NPI:1881466902
Name:IGNITE WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:IGNITE WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-469-3929
Mailing Address - Street 1:101 W MULLAN AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-9217
Mailing Address - Country:US
Mailing Address - Phone:208-469-3929
Mailing Address - Fax:
Practice Address - Street 1:101 W MULLAN AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9217
Practice Address - Country:US
Practice Address - Phone:208-469-3929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty