Provider Demographics
NPI:1861104705
Name:SPARK PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:SPARK PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-812-6145
Mailing Address - Street 1:1763 DUTCH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-5044
Mailing Address - Country:US
Mailing Address - Phone:516-812-6145
Mailing Address - Fax:516-812-6144
Practice Address - Street 1:1763 DUTCH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-5044
Practice Address - Country:US
Practice Address - Phone:516-812-6145
Practice Address - Fax:516-812-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty