Provider Demographics
NPI:1538300462
Name:SPARC LATHAM
Entity Type:Organization
Organization Name:SPARC LATHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-783-5381
Mailing Address - Street 1:636 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4002
Mailing Address - Country:US
Mailing Address - Phone:518-783-5381
Mailing Address - Fax:518-783-0125
Practice Address - Street 1:636 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4002
Practice Address - Country:US
Practice Address - Phone:518-783-5381
Practice Address - Fax:518-783-0125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. PETER'S HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management