Provider Demographics
NPI:1528194925
Name:PAK PODIATRY CORP.
Entity Type:Organization
Organization Name:PAK PODIATRY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SANG(JAMES)
Authorized Official - Middle Name:JOON
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-782-0411
Mailing Address - Street 1:6817 BALBOA BLVD
Mailing Address - Street 2:#B
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4543
Mailing Address - Country:US
Mailing Address - Phone:818-782-0411
Mailing Address - Fax:818-782-0532
Practice Address - Street 1:6817 BALBOA BLVD
Practice Address - Street 2:#B
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4543
Practice Address - Country:US
Practice Address - Phone:818-782-0411
Practice Address - Fax:818-782-0532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4251261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4251OtherSTATE LICENSE NUMBER
CAU79896Medicare UPIN
CAE4251OtherSTATE LICENSE NUMBER
CAW17271BMedicare PIN