Provider Demographics
NPI:1922418870
Name:KENNETH K. PARK, M.D., INC.
Entity Type:Organization
Organization Name:KENNETH K. PARK, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-316-6190
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:
Practice Address - Street 1:23456 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-316-6190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNETH K. PARK, M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-30
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108380332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site