Provider Demographics
NPI:1154432185
Name:SPARKS, WADE DUNCAN (RKT)
Entity type:Individual
Prefix:MR
First Name:WADE
Middle Name:DUNCAN
Last Name:SPARKS
Suffix:
Gender:M
Credentials:RKT
Other - Prefix:MR
Other - First Name:WADE
Other - Middle Name:
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED KINESIOTH
Mailing Address - Street 1:59 LOGGERHEAD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7911
Mailing Address - Country:US
Mailing Address - Phone:803-699-9887
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1377226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist