MEDICARE: THERESA SPARKES L.AC

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	171100000X	Acupuncturist	25MZ00117600	NJ

General Provider Information

NPI Number	:	1891155651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA SPARKES L.AC

Provider Business Mailing Address
First Line	:	18 SLATE HILL TER
Second Line	:
City	:	GREENWOOD LAKE
State	:	NY
Zip	:	10925-4010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	87 STATE RT 17 N
Second Line	:
City	:	MAYWOOD
State	:	NJ
Zip	:	07607-1017
Country	:	US
Telephone Number	:	973-798-8457
Fax Number	:

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

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	03/07/2016

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Directions to “ THERESA SPARKES L.AC” Practice Location

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