Provider Demographics
NPI:1184048001
Name:PARK, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S BERENDO ST APT 119
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4310
Practice Address - Country:US
Practice Address - Phone:213-639-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner