Provider Demographics
NPI:1831752252
Name:SPARK REHAB SPECIALIST LLC
Entity type:Organization
Organization Name:SPARK REHAB SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:VERGARA
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:361-389-4285
Mailing Address - Street 1:6025 TAPESTRY DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6334
Mailing Address - Country:US
Mailing Address - Phone:361-389-4285
Mailing Address - Fax:
Practice Address - Street 1:6025 TAPESTRY DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-6334
Practice Address - Country:US
Practice Address - Phone:361-389-4285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy