Provider Demographics
NPI:1760093454
Name:SPARK PHYSICIAN ASSISTANT SERVICES, INC.
Entity Type:Organization
Organization Name:SPARK PHYSICIAN ASSISTANT SERVICES, INC.
Other - Org Name:SPARK PSYCHEDELIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIBAO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:323-379-3611
Mailing Address - Street 1:3031 S DENISON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-6703
Mailing Address - Country:US
Mailing Address - Phone:786-599-0360
Mailing Address - Fax:
Practice Address - Street 1:3031 S DENISON AVE
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-6703
Practice Address - Country:US
Practice Address - Phone:323-379-3611
Practice Address - Fax:786-629-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty