MEDICARE: KIDSPARK SH INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1366338139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDSPARK SH INC

Provider Business Mailing Address
First Line	:	44 BLYTHE PL
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-1107
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 BLYTHE PL
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-1107
Country	:	US
Telephone Number	:	646-327-6440
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAKHNOZA NAZAROVA
Credential	:
Telephone Number	:	646-327-6440

Provider Enumeration Date	:	06/17/2025
Last Update Date	:	06/17/2025

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