Provider Demographics
NPI:1659690238
Name:CANNON SPARKS MASSAGE LLC
Entity Type:Organization
Organization Name:CANNON SPARKS MASSAGE LLC
Other - Org Name:ELEMENTS THERAPEUTIC MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-448-9398
Mailing Address - Street 1:3209 E 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-7040
Mailing Address - Country:US
Mailing Address - Phone:509-448-9398
Mailing Address - Fax:509-315-8354
Practice Address - Street 1:3209 E 57TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7040
Practice Address - Country:US
Practice Address - Phone:509-448-9398
Practice Address - Fax:509-315-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-22
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty