Provider Demographics
NPI:1295313443
Name:PARK, KEVIN SEIL (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SEIL
Last Name:PARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 S CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-7500
Mailing Address - Country:US
Mailing Address - Phone:909-835-6708
Mailing Address - Fax:
Practice Address - Street 1:915 S CAMERON ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7500
Practice Address - Country:US
Practice Address - Phone:909-835-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist