Healthcare Provider Details

I. General information

NPI: 1710101092
Provider Name (Legal Business Name): DR. KEITH PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 PARK AVE
CALIMESA CA
92320-1148
US

IV. Provider business mailing address

PO BOX 1526
YUCAIPA CA
92399-1435
US

V. Phone/Fax

Practice location:
  • Phone: 909-518-3886
  • Fax: 909-790-9333
Mailing address:
  • Phone: 909-518-3886
  • Fax: 909-790-9333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0085201
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 18884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: