Provider Demographics
NPI:1780069187
Name:IL HWAN PARK CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:IL HWAN PARK CHIROPRACTIC CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-249-0422
Mailing Address - Street 1:4155 MOORPARK AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117
Mailing Address - Country:US
Mailing Address - Phone:408-249-0422
Mailing Address - Fax:408-249-0430
Practice Address - Street 1:4155 MOORPARK AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117
Practice Address - Country:US
Practice Address - Phone:408-249-0422
Practice Address - Fax:408-249-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA123188OtherPTAN
CACA123187OtherMEDICARE PTAN