Healthcare Provider Details

I. General information

NPI: 1376246884
Provider Name (Legal Business Name): SPARK MED SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 05/28/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8027 N GOVERNMENT WAY SUITE 106
HAYDEN ID
83835
US

IV. Provider business mailing address

PO BOX 1021
ATHOL ID
83801-6009
US

V. Phone/Fax

Practice location:
  • Phone: 208-241-9422
  • Fax:
Mailing address:
  • Phone: 208-241-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBBIE J GARRETT
Title or Position: CO-OWNER/DIRECTOR
Credential: RN
Phone: 208-251-2660