Provider Demographics
NPI:1578065975
Name:PARK, CECILIA YURI
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:YURI
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 CARROLL CANYON RD STE 226
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1780
Mailing Address - Country:US
Mailing Address - Phone:619-786-0231
Mailing Address - Fax:
Practice Address - Street 1:3440 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2101
Practice Address - Country:US
Practice Address - Phone:213-399-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor