=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811104631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YONG HWAN PARK, DC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11704 WILSHIRE BLVD SUITE 265
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-444-0058
-----------------------------------------------------
Fax | 310-575-4069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11704 WILSHIRE BLVD SUITE 265
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-444-0058
-----------------------------------------------------
Fax | 310-575-4069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. YONG HWAN PARK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 310-444-0058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC29661
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------