Healthcare Provider Details

I. General information

NPI: 1356297717
Provider Name (Legal Business Name): SPARK WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 COLUMBIA RD
MARTINEZ GA
30907-2221
US

IV. Provider business mailing address

1407 AYLESBURY DR
EVANS GA
30809-8214
US

V. Phone/Fax

Practice location:
  • Phone: 706-250-1151
  • Fax:
Mailing address:
  • Phone: 706-250-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. KIMBERLY M TAYLOR
Title or Position: MANAGING MEMBER
Credential: PT
Phone: 706-250-1151