Healthcare Provider Details

I. General information

NPI: 1700568284
Provider Name (Legal Business Name): JOSEPH PARK CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 W OLYMPIC BLVD STE 113
LOS ANGELES CA
90006-2641
US

IV. Provider business mailing address

212 S MUIRFIELD RD
LOS ANGELES CA
90004-3731
US

V. Phone/Fax

Practice location:
  • Phone: 310-507-3681
  • Fax:
Mailing address:
  • Phone: 310-507-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCOA00648
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberC52271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: