Provider Demographics
NPI:1174316350
Name:VIVID SPARK LLC
Entity type:Organization
Organization Name:VIVID SPARK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-206-6018
Mailing Address - Street 1:773 BRENTMEAD DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6077
Mailing Address - Country:US
Mailing Address - Phone:678-206-6018
Mailing Address - Fax:678-669-2659
Practice Address - Street 1:1590 ATKINSON RD STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5674
Practice Address - Country:US
Practice Address - Phone:678-206-6018
Practice Address - Fax:678-669-2659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care