Healthcare Provider Details

I. General information

NPI: 1003281312
Provider Name (Legal Business Name): SPARK45 FITNESS AND PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 MAPLE ST B
CARPINTERIA CA
93013-3559
US

IV. Provider business mailing address

550 MAPLE ST B
CARPINTERIA CA
93013-3559
US

V. Phone/Fax

Practice location:
  • Phone: 805-275-3000
  • Fax:
Mailing address:
  • Phone: 805-275-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number42251
License Number StateCA

VIII. Authorized Official

Name: DANIELLE BORDENAVE
Title or Position: OWNER/CEO
Credential:
Phone: 773-623-9527