Healthcare Provider Details

I. General information

NPI: 1174316350
Provider Name (Legal Business Name): VIVID SPARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 ATKINSON RD STE 101
LAWRENCEVILLE GA
30043-5674
US

IV. Provider business mailing address

773 BRENTMEAD DR
LAWRENCEVILLE GA
30044-6077
US

V. Phone/Fax

Practice location:
  • Phone: 678-206-6018
  • Fax: 678-669-2659
Mailing address:
  • Phone: 678-206-6018
  • Fax: 678-669-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: FARAH S BAIG
Title or Position: PART OWNER
Credential: MD
Phone: 678-206-6018