Provider Demographics
NPI:1285964932
Name:ICE20 - TRIAD SPORTS GROUP, LLC
Entity type:Organization
Organization Name:ICE20 - TRIAD SPORTS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-857-4172
Mailing Address - Street 1:4690 CALLE QUETZAL
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8558
Mailing Address - Country:US
Mailing Address - Phone:805-857-4172
Mailing Address - Fax:
Practice Address - Street 1:4690 CALLE QUETZAL
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8558
Practice Address - Country:US
Practice Address - Phone:805-857-4172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIAD SPORTS GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-31
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies