Provider Demographics
NPI:1437296928
Name:PARK, KI B (DC)
Entity Type:Individual
Prefix:DR
First Name:KI
Middle Name:B
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 1:1201 S. BEACH BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631
Mailing Address - Country:US
Mailing Address - Phone:562-902-1223
Mailing Address - Fax:
Practice Address - Street 1:1201 S. BEACH BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:562-902-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04399Medicare UPIN
CADC28587Medicare ID - Type Unspecified