Provider Demographics
NPI:1053850297
Name:SPARKS RESIDENTIAL AND SUPPORT SERVICES, INC
Entity Type:Organization
Organization Name:SPARKS RESIDENTIAL AND SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-583-0710
Mailing Address - Street 1:1762 27TH LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-9702
Mailing Address - Country:US
Mailing Address - Phone:719-583-0710
Mailing Address - Fax:
Practice Address - Street 1:507 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1556
Practice Address - Country:US
Practice Address - Phone:719-569-7962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities