Healthcare Provider Details

I. General information

NPI: 1245351808
Provider Name (Legal Business Name): BEACON COMMUNITY MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 W OLYMPIC BLVD
LOS ANGELES CA
90006-3705
US

IV. Provider business mailing address

2017 W OLYMPIC BLVD
LOS ANGELES CA
90006-3705
US

V. Phone/Fax

Practice location:
  • Phone: 213-480-1000
  • Fax: 213-401-0018
Mailing address:
  • Phone: 213-480-1000
  • Fax: 213-401-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC29535
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA54010
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number20A8246
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM JONATHAN PARK
Title or Position: CEO
Credential: D.C.
Phone: 213-480-1000