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General NPI Number Information
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NPI Number | 1003281312
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Entity Type | Organization
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Legal Business Name | SPARK45 FITNESS AND PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 02/12/2016
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Provider Practice Location Address
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Address Line | 550 MAPLE ST B
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City | CARPINTERIA
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State | CA
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Zip | 93013-3559
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Country | US
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Telephone | 805-275-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 550 MAPLE ST B
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City | CARPINTERIA
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State | CA
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Zip | 93013-3559
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Country | US
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Telephone | 805-275-3000
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DANIELLE BORDENAVE
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Credential |
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Telephone | 773-623-9527
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 42251
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License Number State | CA
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