Ice20 - Triad Sports Group, LLC

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

Legal business name

ICE20 - TRIAD SPORTS GROUP, LLC

Practice address

4690 Calle Quetzal
Camarillo, CA 93012-8558

Phone

(805) 857-4172

NPI assigned

Dec 31, 2009

Organization subpart

Yes

Parent organization

TRIAD SPORTS GROUP, LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Brad L Smith

Title

Division President

Phone

(805) 857-4172

Specialties & licenses 1

Addresses

Part of

Ice20 - Triad Sports Group LLC

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1262217600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1412640000000",
    "number": "1285964932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4690 CALLE QUETZAL",
            "city": "CAMARILLO",
            "state": "CA",
            "postal_code": "930128558",
            "telephone_number": "805-857-4172"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4690 CALLE QUETZAL",
            "city": "CAMARILLO",
            "state": "CA",
            "postal_code": "930128558",
            "telephone_number": "805-857-4172"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICE20 - TRIAD SPORTS GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "TRIAD SPORTS GROUP, LLC",
        "enumeration_date": "2009-12-31",
        "last_updated": "2014-10-07",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "BRAD",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "DIVISION PRESIDENT",
        "authorized_official_telephone_number": "805-857-4172"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Durable Medical Equipment & Medical Supplies in Camarillo, CA
• Providers in Camarillo, CA by specialty
• Durable Medical Equipment & Medical Supplies in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.