Provider Demographics
NPI:1710013453
Name:PARK, CHRISTOPHER ANDREW (OTR)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ANDREW
Last Name:PARK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 CENTENNIAL BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3378
Mailing Address - Country:US
Mailing Address - Phone:541-988-5883
Mailing Address - Fax:
Practice Address - Street 1:1717 CENTENNIAL BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3378
Practice Address - Country:US
Practice Address - Phone:541-988-5883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR981837225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR041645Medicaid