1508967290 NPI number — MARY SUE SPARKS R.PSGT/ CRT

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 1508967290 NPI number — MARY SUE SPARKS R.PSGT/ CRT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
MARY
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.PSGT/ CRT
Provider Gender Code:
F

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:
1508967290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7360 188TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC ALPIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32062-2757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-288-8586
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 SW ARCHER RD
Provider Second Line Business Practice Location Address:
SLEEP LAB # 111
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32608-1135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-376-1611
Provider Business Practice Location Address Fax Number:
352-379-4155
Provider Enumeration Date:
09/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 227800000X , with the licence number:  TT8225 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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