Healthcare Provider Details

I. General information

NPI: 1447354014
Provider Name (Legal Business Name): SPARKS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 S. LOGAN ST.
CHARLESTON AR
72933
US

IV. Provider business mailing address

PO BOX 2420
FORT SMITH AR
72902-2420
US

V. Phone/Fax

Practice location:
  • Phone: 479-965-7702
  • Fax: 479-965-2180
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateAR

VIII. Authorized Official

Name: REBECCA COX
Title or Position: CBO SUPPORT MANAGER
Credential:
Phone: 479-709-7057