Healthcare Provider Details

I. General information

NPI: 1376014373
Provider Name (Legal Business Name): CHARLENE SPARKS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 S TUSTIN ST
ORANGE CA
92866-2501
US

IV. Provider business mailing address

393 S TUSTIN ST
ORANGE CA
92866-2501
US

V. Phone/Fax

Practice location:
  • Phone: 714-289-2400
  • Fax:
Mailing address:
  • Phone: 714-289-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: