Basic Information
Provider Information
NPI: 1982195624
EntityType: 2
ReplacementNPI:  
OrganizationName: SPARK PERFORMANCE AND PHYSIOTHERAPY
LastName:  
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Mailing Information
Address1: 6056 EAST BASELINE ROAD
Address2: SUITE 147
City: MESA
State: AZ
PostalCode: 85206
CountryCode: US
TelephoneNumber: 4804529191
FaxNumber: 4805341113
Practice Location
Address1: 6056 EAST BASLINE ROAD
Address2: SUITE 147
City: MESA
State: AZ
PostalCode: 85206
CountryCode: US
TelephoneNumber: 4804529191
FaxNumber: 4805341113
Other Information
ProviderEnumerationDate: 05/29/2018
LastUpdateDate: 07/25/2018
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: ALEXANDER
AuthorizedOfficialFirstName: STEVEN
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AuthorizedOfficialTitleorPosition: CEO/DIRECTOR
AuthorizedOfficialTelephone: 4804529191
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PT, DPT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QP2000X  Y Ambulatory Health Care FacilitiesClinic/CenterPhysical Therapy

No ID Information.


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