MEDICARE: MS. SANDRA 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	225700000X	Massage Therapist	41602	KY

General Provider Information

NPI Number	:	1790115988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA SPARKS

Provider Business Mailing Address
First Line	:	736 RUNNING CREEK DR
Second Line	:	#5
City	:	SHEPHERDSVILLE
State	:	KY
Zip	:	40165-6964
Country	:	US
Telephone Number	:	502-553-2508
Fax Number	:

Provider Business Practice Location Address
First Line	:	4008 PRESTON HWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40213-1612
Country	:	US
Telephone Number	:	502-368-1413
Fax Number	:

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

Provider Enumeration Date	:	11/25/2013
Last Update Date	:	11/25/2013

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