Provider Demographics
NPI:1043072218
Name:BOLD SPARK, INC.
Entity Type:Organization
Organization Name:BOLD SPARK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:V
Authorized Official - Last Name:LIEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-329-6709
Mailing Address - Street 1:218 GINGERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4624
Mailing Address - Country:US
Mailing Address - Phone:630-329-6709
Mailing Address - Fax:
Practice Address - Street 1:820 S BARTLETT RD STE 106B
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-2407
Practice Address - Country:US
Practice Address - Phone:224-318-7554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOLD SPARK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-24
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245414465OtherNPI