Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC32033 | CA |
NPI | 1417214750 |
---|---|
Provider Name | Mr. Peter Park |
First Address | Montebello, CA 90640-3964 |
Second Address | Montebello, CA 90640-3964 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2012 |
Last Update Date | 11/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC32033 | CALIFORNIA STATE LICENCE (01) | CA |