Provider Demographics
NPI:1801120332
Name:SPARKS, BRYON KENT (LIC AC)
Entity type:Individual
Prefix:MR
First Name:BRYON
Middle Name:KENT
Last Name:SPARKS
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 LIKO PL
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1214
Mailing Address - Country:US
Mailing Address - Phone:808-205-8454
Mailing Address - Fax:
Practice Address - Street 1:2045 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1648
Practice Address - Country:US
Practice Address - Phone:808-205-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI699171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist