Provider Demographics
NPI:1255471579
Name:PARK, ROBERT E (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
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 1:174 W PARRISH LN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1821
Mailing Address - Country:US
Mailing Address - Phone:801-706-4353
Mailing Address - Fax:801-295-5434
Practice Address - Street 1:174 W PARRISH LN
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-1821
Practice Address - Country:US
Practice Address - Phone:801-706-4353
Practice Address - Fax:801-295-5434
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176374-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor