Provider Demographics
NPI:1003281312
Name:SPARK45 FITNESS AND PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SPARK45 FITNESS AND PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDENAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-623-9527
Mailing Address - Street 1:550 MAPLE ST
Mailing Address - Street 2:B
Mailing Address - City:CARPINTERIA
Mailing Address - State:CA
Mailing Address - Zip Code:93013-3559
Mailing Address - Country:US
Mailing Address - Phone:805-275-3000
Mailing Address - Fax:
Practice Address - Street 1:550 MAPLE ST
Practice Address - Street 2:B
Practice Address - City:CARPINTERIA
Practice Address - State:CA
Practice Address - Zip Code:93013-3559
Practice Address - Country:US
Practice Address - Phone:805-275-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42251261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy