Provider Demographics
NPI:1851729719
Name:SPARKS, LARRY
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10476 131ST ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-4734
Mailing Address - Country:US
Mailing Address - Phone:727-593-5569
Mailing Address - Fax:727-593-3140
Practice Address - Street 1:10476 131ST ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-4734
Practice Address - Country:US
Practice Address - Phone:727-593-5569
Practice Address - Fax:727-593-3140
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8317171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator