Provider Demographics
NPI:1265075964
Name:SPARKS, BEAU WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:BEAU
Middle Name:WILLIAM
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N MEADOWWOOD LN STE 80
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-6021
Mailing Address - Country:US
Mailing Address - Phone:360-980-0614
Mailing Address - Fax:
Practice Address - Street 1:1421 N MEADOWWOOD LN STE 80
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-6021
Practice Address - Country:US
Practice Address - Phone:360-980-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor