Healthcare Provider Details

I. General information

NPI: 1700025293
Provider Name (Legal Business Name): SPARKS MASSAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E HASTINGS RD
SPOKANE WA
99218-3607
US

IV. Provider business mailing address

101 E HASTINGS RD
SPOKANE WA
99218-3607
US

V. Phone/Fax

Practice location:
  • Phone: 509-340-3303
  • Fax:
Mailing address:
  • Phone: 509-340-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMA60058182
License Number StateWA

VIII. Authorized Official

Name: MR. STEVEN SPARKS
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-340-3303