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General NPI Number Information
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NPI Number | 1619126323
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Entity Type | Organization
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Legal Business Name | CHANUN PARK DO PA
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Dates
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Enumeration Date | 09/17/2008
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Last Update Date | 11/24/2008
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Provider Practice Location Address
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Address Line | 1220 BUSINESS WAY UNIT 1
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City | LEHIGH ACRES
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State | FL
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Zip | 33936-6007
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Country | US
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Telephone | 239-369-4155
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Fax | 239-369-1950
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Provider Business Mailing Address
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Address Line | 1220 BUSINESS WAY UNIT 1
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City | LEHIGH ACRES
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State | FL
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Zip | 33936-6007
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Country | US
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Telephone | 239-369-4155
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Fax | 239-369-1950
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHANUN DUSTIN PARK
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Credential | D.O.
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Telephone | 239-369-4155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | OS8128
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License Number State | FL
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