Healthcare Provider Details

I. General information

NPI: 1831284967
Provider Name (Legal Business Name): SPARKS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N. HUDSON ST.
SILVER CITY NM
88061
US

IV. Provider business mailing address

1000 N. HUDSON ST.
SILVER CITY NM
88061
US

V. Phone/Fax

Practice location:
  • Phone: 505-538-0486
  • Fax: 505-538-9179
Mailing address:
  • Phone: 505-538-0486
  • Fax: 505-538-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number87-386NM
License Number StateNM

VIII. Authorized Official

Name: TWANA LIVETTE SPARKS
Title or Position: PRESIDENT
Credential: MD
Phone: 505-538-0486