Provider Demographics
NPI:1922188754
Name:PARK, JAMES R (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2035
Mailing Address - Country:US
Mailing Address - Phone:801-393-2424
Mailing Address - Fax:801-394-3451
Practice Address - Street 1:1096 36TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2035
Practice Address - Country:US
Practice Address - Phone:801-393-2424
Practice Address - Fax:801-394-3451
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2374236-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU89636Medicare UPIN
UT000056310Medicare PIN