Provider Demographics
NPI:1376246884
Name:SPARK MED SPA, LLC
Entity Type:Organization
Organization Name:SPARK MED SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-251-2660
Mailing Address - Street 1:PO BOX 1021
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-6009
Mailing Address - Country:US
Mailing Address - Phone:208-241-9942
Mailing Address - Fax:
Practice Address - Street 1:33616 N SHEEP SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-8306
Practice Address - Country:US
Practice Address - Phone:208-241-9422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARK MED SPA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service