Provider Demographics
NPI:1942075668
Name:PARK, ROBERT B (LVN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:PARK
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2656
Mailing Address - Country:US
Mailing Address - Phone:818-244-7219
Mailing Address - Fax:818-240-1069
Practice Address - Street 1:1230 E WINDSOR RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2656
Practice Address - Country:US
Practice Address - Phone:818-244-7219
Practice Address - Fax:818-240-1069
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA241313164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse