Healthcare Provider Details

I. General information

NPI: 1881210318
Provider Name (Legal Business Name): LIVINGSTONE COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 06/20/2020
Certification Date: 06/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W BASTANCHURY RD UNIT 1A
FULLERTON CA
92835-2527
US

IV. Provider business mailing address

111 W BASTANCHURY RD UNIT 1A
FULLERTON CA
92835-2527
US

V. Phone/Fax

Practice location:
  • Phone: 714-248-9500
  • Fax: 714-622-4943
Mailing address:
  • Phone: 714-248-9500
  • Fax: 714-622-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. KYUNG I. PARK
Title or Position: CEO
Credential: MD
Phone: 714-248-9500