Provider Demographics
NPI:1417226804
Name:BACK TO WORK ORTHOPEDIC MEDICAL GROUP
Entity Type:Organization
Organization Name:BACK TO WORK ORTHOPEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-633-2273
Mailing Address - Street 1:5203 LAKEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-2438
Mailing Address - Country:US
Mailing Address - Phone:562-633-2273
Mailing Address - Fax:
Practice Address - Street 1:5203 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2438
Practice Address - Country:US
Practice Address - Phone:562-633-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization