MEDICARE: SHANI PARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316595150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANI PARK

Provider Business Mailing Address
First Line	:	2215 ALCAZAR ST APT 324
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1003
Country	:	US
Telephone Number	:	623-262-5275
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 ALCAZAR ST APT 324
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90033-1003
Country	:	US
Telephone Number	:	623-262-5275
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2019
Last Update Date	:	08/26/2019

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Directions to “ SHANI PARK ” Practice Location

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