Healthcare Provider Details

I. General information

NPI: 1336311539
Provider Name (Legal Business Name): KP MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 E WASHINGTON BLVD SUITE A-1
LOS ANGELES CA
90021-3020
US

IV. Provider business mailing address

1005 E WASHINGTON BLVD SUITE A-1
LOS ANGELES CA
90021-3020
US

V. Phone/Fax

Practice location:
  • Phone: 213-745-3636
  • Fax: 213-745-3626
Mailing address:
  • Phone: 213-745-3636
  • Fax: 213-745-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. KERRY PARK
Title or Position: OWNER
Credential: MD
Phone: 213-746-3636