Provider Demographics
NPI:1750042446
Name:SPARK PHYSICAL THERAPY & SPORTS PERFORMANCE INC
Entity Type:Organization
Organization Name:SPARK PHYSICAL THERAPY & SPORTS PERFORMANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZIAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHDUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-335-3182
Mailing Address - Street 1:8575 1/2 KNOTT AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3850
Mailing Address - Country:US
Mailing Address - Phone:714-335-3182
Mailing Address - Fax:
Practice Address - Street 1:8575 1/2 KNOTT AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3850
Practice Address - Country:US
Practice Address - Phone:714-335-3182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy