Healthcare Provider Details

I. General information

NPI: 1477800662
Provider Name (Legal Business Name): LELAND L SPARKS BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5331
  • Fax: 702-385-5678
Mailing address:
  • Phone: 419-695-8010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: