MEDICARE: SPARC OCCUPATIONAL AND PHYSICAL THERAPY SERVICES

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	225XP0200X	Pediatric Occupational Therapist	003402	NY
2	2251P0200X	Pediatric Physical Therapist	012187	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	003402	OTHER	NY	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1679983613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARC OCCUPATIONAL AND PHYSICAL THERAPY SERVICES

Provider Business Mailing Address
First Line	:	595 BLOSSOM RD
Second Line	:	SUITE 308
City	:	ROCHESTER
State	:	NY
Zip	:	14610-1825
Country	:	US
Telephone Number	:	585-355-4071
Fax Number	:	585-355-4071

Provider Business Practice Location Address
First Line	:	595 BLOSSOM RD
Second Line	:	SUITE 308
City	:	ROCHESTER
State	:	NY
Zip	:	14610-1825
Country	:	US
Telephone Number	:	585-355-4071
Fax Number	:	585-355-4071

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARGARET M ORLANDO
Credential	:	OTR
Telephone Number	:	585-748-5689

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	04/29/2014

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