Healthcare Provider Details

I. General information

NPI: 1740238823
Provider Name (Legal Business Name): SPARKS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DODSON AVE STE 140
FORT SMITH AR
72901-5182
US

IV. Provider business mailing address

PO BOX 2420
FORT SMITH AR
72902-2420
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-1913
  • Fax: 479-709-1998
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471M2300X
TaxonomyMammography Radiologic Technologist
License NumberRT2641
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License NumberRT2641
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License NumberRT2641
License Number StateAR

VIII. Authorized Official

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