Healthcare Provider Details

I. General information

NPI: 1396569497
Provider Name (Legal Business Name): SPARKLE WAFER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77711 FLORA RD STE 327
PALM DESERT CA
92211-4103
US

IV. Provider business mailing address

77711 FLORA RD # 327
PALM DESERT CA
92211-4103
US

V. Phone/Fax

Practice location:
  • Phone: 800-465-3203
  • Fax: 888-588-2752
Mailing address:
  • Phone: 800-465-3203
  • Fax: 888-588-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: