Healthcare Provider Details

I. General information

NPI: 1417511387
Provider Name (Legal Business Name): SPARKFIT COMMUNITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MAIN ST STE 204
LITTLE ROCK AR
72202-5057
US

IV. Provider business mailing address

1324B MAIN ST
LITTLE ROCK AR
72202-5034
US

V. Phone/Fax

Practice location:
  • Phone: 501-428-3217
  • Fax:
Mailing address:
  • Phone: 501-400-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GLENN MCCRACKEN
Title or Position: OWNER
Credential: LPC
Phone: 501-428-3217