Provider Demographics
NPI:1689202541
Name:IMPERIAL CLINIC
Entity Type:Organization
Organization Name:IMPERIAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-902-1223
Mailing Address - Street 1:1201 S BEACH BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6366
Mailing Address - Country:US
Mailing Address - Phone:562-902-1223
Mailing Address - Fax:
Practice Address - Street 1:1201 S BEACH BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6366
Practice Address - Country:US
Practice Address - Phone:562-902-1223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty