Provider Demographics
NPI:1588346787
Name:SPARKS, PRESTON
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 FIELDFARE DR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2532
Mailing Address - Country:US
Mailing Address - Phone:478-952-3782
Mailing Address - Fax:
Practice Address - Street 1:2669 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-8400
Practice Address - Country:US
Practice Address - Phone:404-477-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist