Provider Demographics
NPI:1184840217
Name:PARK, ANDREW (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 W 9TH ST
Mailing Address - Street 2:1
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3436
Mailing Address - Country:US
Mailing Address - Phone:714-388-2461
Mailing Address - Fax:
Practice Address - Street 1:4482 BARRANCA PKWY
Practice Address - Street 2:SUITE 192
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-7701
Practice Address - Country:US
Practice Address - Phone:949-552-5094
Practice Address - Fax:949-552-5096
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30265111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor