1356580468 NPI number — SPARKLE MEDICAL PA

Table of content: (NPI 1356580468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356580468 NPI number — SPARKLE MEDICAL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARKLE MEDICAL PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356580468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 PARK AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SO. PLAINFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-548-8355
Provider Business Mailing Address Fax Number:
908-548-8359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 PARK AVENUE
Provider Second Line Business Practice Location Address:
SUIT 104
Provider Business Practice Location Address City Name:
SOUTH PLAINFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-548-8355
Provider Business Practice Location Address Fax Number:
908-548-8359
Provider Enumeration Date:
02/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RAO
Authorized Official First Name:
SEEMA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
908-548-8355

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0220868 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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