Provider Demographics
NPI:1467704957
Name:JAMES PARK
Entity Type:Organization
Organization Name:JAMES PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-514-2900
Mailing Address - Street 1:6501 EAGLE ROCK AVE NE
Mailing Address - Street 2:SUITE A6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2478
Mailing Address - Country:US
Mailing Address - Phone:505-514-2900
Mailing Address - Fax:
Practice Address - Street 1:6501 EAGLE ROCK AVE NE
Practice Address - Street 2:SUITE A6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2478
Practice Address - Country:US
Practice Address - Phone:505-514-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM866RX1171100000X
NM2074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45139024Medicaid
7645703OtherAETNA
7645703OtherAETNA