Healthcare Provider Details

I. General information

NPI: 1669301610
Provider Name (Legal Business Name): CAROLINE PARK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: