MEDICARE: PRESTON SPARKS

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	225100000X	Physical Therapist	PT016725	GA

General Provider Information

NPI Number	:	1588346787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRESTON SPARKS

Provider Business Mailing Address
First Line	:	105 FIELDFARE DR
Second Line	:
City	:	KATHLEEN
State	:	GA
Zip	:	31047-2532
Country	:	US
Telephone Number	:	478-952-3782
Fax Number	:

Provider Business Practice Location Address
First Line	:	2669 OSBORNE RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-8400
Country	:	US
Telephone Number	:	404-477-7777
Fax Number	:

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

Provider Enumeration Date	:	08/07/2023
Last Update Date	:	08/07/2023

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Directions to “ PRESTON SPARKS ” Practice Location

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