Provider Demographics
NPI:1235312935
Name:CHRIS J PARK DPM, INC
Entity Type:Organization
Organization Name:CHRIS J PARK DPM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:626-913-0948
Mailing Address - Street 1:14839 COUNTRY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5161
Mailing Address - Country:US
Mailing Address - Phone:909-241-6511
Mailing Address - Fax:
Practice Address - Street 1:18895 COLIMA RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2978
Practice Address - Country:US
Practice Address - Phone:626-913-0948
Practice Address - Fax:626-854-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4168261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41680Medicaid
CA000E41680Medicaid
6032080001Medicare NSC
CAW21890Medicare PIN