Provider Demographics
NPI:1811104631
Name:YONG HWAN PARK, DC
Entity type:Organization
Organization Name:YONG HWAN PARK, DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YONG HWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-444-0058
Mailing Address - Street 1:11704 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 265
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1507
Mailing Address - Country:US
Mailing Address - Phone:310-444-0058
Mailing Address - Fax:310-575-4069
Practice Address - Street 1:11704 WILSHIRE BLVD
Practice Address - Street 2:SUITE 265
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1507
Practice Address - Country:US
Practice Address - Phone:310-444-0058
Practice Address - Fax:310-575-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV10725Medicare UPIN