MEDICARE: SPARKS HOSPICE CARE LLC

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1801525746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARKS HOSPICE CARE LLC

Provider Business Mailing Address
First Line	:	2100 S MARYLAND PKWY STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-3225
Country	:	US
Telephone Number	:	818-267-7945
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 S MARYLAND PKWY STE 9
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-3225
Country	:	US
Telephone Number	:	818-267-7945
Fax Number	:

Authorized Official
Title or Position	:	CEO/CFO/ADMINISTRATOR
Name	:	DOMINGO BACCAY JR.
Credential	:
Telephone Number	:	818-267-7945

Provider Enumeration Date	:	06/07/2022
Last Update Date	:	09/27/2022

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