Healthcare Provider Details

I. General information

NPI: 1407051683
Provider Name (Legal Business Name): SPARK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 S LOUDOUN ST
WINCHESTER VA
22601-3612
US

IV. Provider business mailing address

2017 S LOUDOUN ST
WINCHESTER VA
22601-3612
US

V. Phone/Fax

Practice location:
  • Phone: 540-665-0571
  • Fax: 540-667-7439
Mailing address:
  • Phone: 540-665-0571
  • Fax: 540-667-7439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD LEE COMER
Title or Position: PRESIDENT
Credential:
Phone: 540-665-0571