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General NPI Number Information
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NPI Number | 1174316350
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Entity Type | Organization
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Legal Business Name | VIVID SPARK LLC
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Dates
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Enumeration Date | 05/28/2025
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Last Update Date | 05/28/2025
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Provider Practice Location Address
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Address Line | 1590 ATKINSON RD STE 101
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5674
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Country | US
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Telephone | 678-206-6018
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Fax | 678-669-2659
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Provider Business Mailing Address
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Address Line | 773 BRENTMEAD DR
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-6077
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Country | US
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Telephone | 678-206-6018
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Fax | 678-669-2659
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Authorized Official
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Title or Position | PART OWNER
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Name | FARAH S BAIG
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Credential | MD
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Telephone | 678-206-6018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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