Provider Demographics
NPI:1679970859
Name:PARK, GRACE (DC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20627 GOLDEN SPRINGS DR.
Mailing Address - Street 2:2-B
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91789
Mailing Address - Country:US
Mailing Address - Phone:909-696-9373
Mailing Address - Fax:
Practice Address - Street 1:20627 GOLDEN SPRINGS DR.
Practice Address - Street 2:2-B
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91789
Practice Address - Country:US
Practice Address - Phone:909-696-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor