Provider Demographics
NPI:1083128094
Name:PARK, MIGUEL (DC)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14671 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5648
Mailing Address - Country:US
Mailing Address - Phone:909-606-7999
Mailing Address - Fax:909-606-8999
Practice Address - Street 1:14671 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5648
Practice Address - Country:US
Practice Address - Phone:909-606-7999
Practice Address - Fax:909-606-8999
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31244111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor