Healthcare Provider Details

I. General information

NPI: 1013514777
Provider Name (Legal Business Name): MICHAEL PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 COLUMBIA AVE STE 200
LOS ANGELES CA
90017-1209
US

IV. Provider business mailing address

515 COLUMBIA AVE STE 200
LOS ANGELES CA
90017-1209
US

V. Phone/Fax

Practice location:
  • Phone: 213-219-5802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: