Provider Demographics
NPI:1649765660
Name:SPARK INSPIRATION LABORATORY, LLC
Entity type:Organization
Organization Name:SPARK INSPIRATION LABORATORY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ZOWIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-571-6906
Mailing Address - Street 1:37 W CENTURY RD, SUITE 100A
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1466
Mailing Address - Country:US
Mailing Address - Phone:862-208-9876
Mailing Address - Fax:
Practice Address - Street 1:37 W CENTURY RD, SUITE 100A
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1466
Practice Address - Country:US
Practice Address - Phone:862-571-6906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0732290Medicaid