Provider Demographics
NPI:1720892862
Name:SPARK DEMENTIA CARE, P.A.
Entity type:Organization
Organization Name:SPARK DEMENTIA CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:M.
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-545-0922
Mailing Address - Street 1:224 W 35TH ST STE 500
Mailing Address - Street 2:#2031
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:212-201-9292
Mailing Address - Fax:
Practice Address - Street 1:224 W 35TH ST STE 500
Practice Address - Street 2:#2031
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:212-201-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty