1508093907 NPI number — MR. KING ANTHONY SPARKS PHLEBOTOMY TECHNICIA

Table of content: MR. KING ANTHONY SPARKS PHLEBOTOMY TECHNICIA (NPI 1508093907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508093907 NPI number — MR. KING ANTHONY SPARKS PHLEBOTOMY TECHNICIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKS
Provider First Name:
KING
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHLEBOTOMY TECHNICIA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508093907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60526
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90060-0526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-926-7970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1254 N WILMINGTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90744-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-926-7970
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  CPT3277799 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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