Healthcare Provider Details

I. General information

NPI: 1457614612
Provider Name (Legal Business Name): J & T PARK ENTERPRISES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 COOKS CORNER RD
POTTSBORO TX
75076-6042
US

IV. Provider business mailing address

788 COOKS CORNER RD
POTTSBORO TX
75076-6042
US

V. Phone/Fax

Practice location:
  • Phone: 806-341-8883
  • Fax:
Mailing address:
  • Phone: 806-341-8883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT04601
License Number StateTX

VIII. Authorized Official

Name: MRS. VICTORIA CUCCIA PARK
Title or Position: REGISTERED DIETITIAN
Credential: R.D. L.D.
Phone: 806-341-8883