Provider Demographics
NPI:1831284967
Name:SPARKS CLINIC PC
Entity Type:Organization
Organization Name:SPARKS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TWANA
Authorized Official - Middle Name:LIVETTE
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-538-0486
Mailing Address - Street 1:1000 N. HUDSON ST.
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061
Mailing Address - Country:US
Mailing Address - Phone:505-538-0486
Mailing Address - Fax:505-538-9179
Practice Address - Street 1:1000 N. HUDSON ST.
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061
Practice Address - Country:US
Practice Address - Phone:505-538-0486
Practice Address - Fax:505-538-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-386NM207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty