Healthcare Provider Details

I. General information

NPI: 1902716145
Provider Name (Legal Business Name): GROWTH BRIDGE SPARKS PCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 S GOODMAN ST
SPARKS GA
31647-7549
US

IV. Provider business mailing address

3116 HOLLY MILL RUN
MARIETTA GA
30062-5460
US

V. Phone/Fax

Practice location:
  • Phone: 229-234-9775
  • Fax:
Mailing address:
  • Phone: 770-609-7610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: LESLIE OFORI
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 770-568-3923