Provider Demographics
NPI:1427210822
Name:WILSON C PARK CHIROPRACTIC CORP
Entity Type:Organization
Organization Name:WILSON C PARK CHIROPRACTIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-869-0536
Mailing Address - Street 1:2940 WESTWOOD BLVD
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-869-0536
Mailing Address - Fax:310-441-3727
Practice Address - Street 1:2940 WESTWOOD BLVD
Practice Address - Street 2:#1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4145
Practice Address - Country:US
Practice Address - Phone:310-869-0536
Practice Address - Fax:310-441-3727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC251660OtherBLUE SHIELD