Provider Demographics
NPI:1083274112
Name:SPARK MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:SPARK MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-469-7980
Mailing Address - Street 1:3175 S CONGRESS AVE STE 305D
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2562
Mailing Address - Country:US
Mailing Address - Phone:561-469-7980
Mailing Address - Fax:
Practice Address - Street 1:3175 S CONGRESS AVE STE 305D
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2562
Practice Address - Country:US
Practice Address - Phone:561-469-7980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-20
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies