Provider Demographics
NPI:1790734572
Name:PARK, JOE W (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:W
Last Name:PARK
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8352 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2526
Mailing Address - Country:US
Mailing Address - Phone:949-701-8250
Mailing Address - Fax:
Practice Address - Street 1:801 N TUSTIN AVE STE 302
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3601
Practice Address - Country:US
Practice Address - Phone:714-564-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29675111N00000X
CADC29675111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC29675AMedicare ID - Type Unspecified
V08596Medicare UPIN