Provider Demographics
NPI:1861013583
Name:SPORA MEDICAL, PC.
Entity Type:Organization
Organization Name:SPORA MEDICAL, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COM
Authorized Official - Prefix:
Authorized Official - First Name:LAKISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-389-1899
Mailing Address - Street 1:4445 CORPORATION LN STE 264
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3262
Mailing Address - Country:US
Mailing Address - Phone:773-389-1899
Mailing Address - Fax:
Practice Address - Street 1:4445 CORPORATION LN STE 264
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3262
Practice Address - Country:US
Practice Address - Phone:773-389-1899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPORA HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-05
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922695949OtherNPI
1346993029OtherNPI