Healthcare Provider Details

I. General information

NPI: 1396796306
Provider Name (Legal Business Name): PAK PODIATRY CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2006
Last Update Date: 01/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 W TEMPLE ST SUITE #3600
LOS ANGELES CA
90026-5421
US

IV. Provider business mailing address

1711 W TEMPLE ST SUITE #3600
LOS ANGELES CA
90026-5421
US

V. Phone/Fax

Practice location:
  • Phone: 213-989-0700
  • Fax: 213-989-0703
Mailing address:
  • Phone: 213-989-0700
  • Fax: 213-989-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberE4251
License Number StateCA

VIII. Authorized Official

Name: DR. SANG JOON PAK
Title or Position: OWNER/PRESIDENT
Credential: D.P.M
Phone: 213-989-0700