MEDICARE: SPARKS DIALYSIS 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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1316511397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKS DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 LONG BEACH BLVD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-5061
Country	:	US
Telephone Number	:	562-988-8866
Fax Number	:

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	JOHN WINSTEL
Credential	:
Telephone Number	:	253-733-4501

Provider Enumeration Date	:	05/14/2021
Last Update Date	:	05/14/2021

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Directions to “SPARKS DIALYSIS LLC ” Practice Location

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