1043308232 NPI number — SPARKS MEDICAL FOUNDATION

Table of content: (NPI 1043308232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043308232 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:
1043308232
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 180
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:
479-573-7870
Provider Business Practice Location Address Fax Number:
479-573-7871
Provider Enumeration Date:
10/11/2006

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: 4454530045 . This is a "M-CARE DME" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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