MEDICARE: KACI AMANDA SPARKS PT

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	2251P0200X	Pediatric Physical Therapist	1200336	TX

General Provider Information

NPI Number	:	1568770584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACI AMANDA SPARKS PT

Provider Business Mailing Address
First Line	:	4601 66TH ST STE D
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-4875
Country	:	US
Telephone Number	:	806-793-3900
Fax Number	:	806-793-3937

Provider Business Practice Location Address
First Line	:	4601 66TH ST STE D
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-4875
Country	:	US
Telephone Number	:	806-793-3900
Fax Number	:	806-793-3937

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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Directions to “ KACI AMANDA SPARKS PT” Practice Location

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