Provider Demographics
NPI:1790880797
Name:SPARKS MEDICAL FOUNDATIN
Entity Type:Organization
Organization Name:SPARKS MEDICAL FOUNDATIN
Other - Org Name:WALDRON PLACE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CBO SUPPORT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-709-7057
Mailing Address - Street 1:PO BOX 2420
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-2420
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1501 S WALDRON RD
Practice Address - Street 2:STE 100
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2574
Practice Address - Country:US
Practice Address - Phone:479-709-7310
Practice Address - Fax:479-709-7315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4454530012OtherM-CARE DME