Healthcare Provider Details

I. General information

NPI: 1760371744
Provider Name (Legal Business Name): DOMINIC PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 MARENGO ST
LOS ANGELES CA
90033-1036
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-1200
  • Fax:
Mailing address:
  • Phone: 626-457-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number308143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: