Provider Demographics
NPI:1417214750
Name:PARK, PETER (DC)
Entity Type:Individual
Prefix:MR
First Name:PETER
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 1:1800 W BEVERLY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3964
Mailing Address - Country:US
Mailing Address - Phone:323-516-6252
Mailing Address - Fax:714-801-7928
Practice Address - Street 1:1800 W BEVERLY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3964
Practice Address - Country:US
Practice Address - Phone:323-516-6252
Practice Address - Fax:714-801-7928
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC32033111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC32033OtherCALIFORNIA STATE LICENCE