Healthcare Provider Details

I. General information

NPI: 1275723645
Provider Name (Legal Business Name): ELAINE A SPARKS HUMAN SERVICE WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE A HOLLEY

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 07/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 E GOBBI ST
UKIAH CA
95482-5551
US

IV. Provider business mailing address

89 BUSH ST
WILLITS CA
95490-3805
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-2922
  • Fax: 707-462-1381
Mailing address:
  • Phone: 707-621-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: