MEDICARE: HEALTH SPARK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1205618840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH SPARK, LLC

Provider Business Mailing Address
First Line	:	4771 N SUMMIT WAY STE 110
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5017
Country	:	US
Telephone Number	:	208-994-4747
Fax Number	:

Provider Business Practice Location Address
First Line	:	4771 N SUMMIT WAY STE 110
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5017
Country	:	US
Telephone Number	:	208-994-4747
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RUSSELL ALLEN
Credential	:	DC
Telephone Number	:	208-994-4747

Provider Enumeration Date	:	10/18/2023
Last Update Date	:	10/23/2023

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Directions to “HEALTH SPARK, LLC ” Practice Location

Language	Start Address	Practice Location

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