Provider Demographics
NPI:1760726574
Name:PARK, JOSEPH (DPT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12465 LEWIS STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4658
Mailing Address - Country:US
Mailing Address - Phone:714-703-8477
Mailing Address - Fax:714-703-8157
Practice Address - Street 1:12465 LEWIS STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4658
Practice Address - Country:US
Practice Address - Phone:714-703-8477
Practice Address - Fax:714-703-8157
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist