Provider Demographics
NPI:1457614612
Name:J & T PARK ENTERPRISES, LTD.
Entity Type:Organization
Organization Name:J & T PARK ENTERPRISES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:CUCCIA
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD
Authorized Official - Phone:806-341-8883
Mailing Address - Street 1:788 COOKS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-6042
Mailing Address - Country:US
Mailing Address - Phone:806-341-8883
Mailing Address - Fax:
Practice Address - Street 1:788 COOKS CORNER RD
Practice Address - Street 2:
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-6042
Practice Address - Country:US
Practice Address - Phone:806-341-8883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04601133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1356573166Medicaid
TXTXB154636OtherMEDICARE PTAN