Healthcare Provider Details

I. General information

NPI: 1295540102
Provider Name (Legal Business Name): SPARX FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6417 PENN AVE S STE 7-70
MINNEAPOLIS MN
55423-1186
US

IV. Provider business mailing address

6417 PENN AVE S STE 7-70
MINNEAPOLIS MN
55423-1186
US

V. Phone/Fax

Practice location:
  • Phone: 952-314-4448
  • Fax:
Mailing address:
  • Phone: 952-314-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FARDOWS O SALIM
Title or Position: MD
Credential: MD
Phone: 952-314-4448