Healthcare Provider Details

I. General information

NPI: 1932331410
Provider Name (Legal Business Name): SEUNG HYUK PARK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8545 SIERRA AVE
FONTANA CA
92335-3868
US

IV. Provider business mailing address

8545 SIERRA AVE
FONTANA CA
92335-3868
US

V. Phone/Fax

Practice location:
  • Phone: 909-365-3557
  • Fax: 909-658-8987
Mailing address:
  • Phone: 909-365-3557
  • Fax: 909-658-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number35680
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT8004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: