Provider Demographics
NPI:1073962791
Name:SPARKLES KC LLC
Entity Type:Organization
Organization Name:SPARKLES KC LLC
Other - Org Name:PATH TO SERENITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:IZZY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-289-0350
Mailing Address - Street 1:8 CHESHIRE CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4210
Mailing Address - Country:US
Mailing Address - Phone:949-289-0350
Mailing Address - Fax:
Practice Address - Street 1:10002 BRILEY WAY
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-4219
Practice Address - Country:US
Practice Address - Phone:949-289-0350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility