1578661328 NPI number — SPARKS MEDICAL FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578661328 NPI number — SPARKS MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARKS MEDICAL FOUNDATION
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:
6
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:
1578661328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72902-2420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-709-7399
Provider Business Mailing Address Fax Number:
479-709-7053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 DODSON AVE
Provider Second Line Business Practice Location Address:
STE 195
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72901-5182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-709-7160
Provider Business Practice Location Address Fax Number:
479-709-7849
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
CBO SUPPORT MANAGER
Authorized Official Telephone Number:
479-709-7057

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4454530053 . This is a "M-CARE DME" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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