MEDICARE: DR. PARK BRIAN MICKELSON DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC24507	CA

General Provider Information

NPI Number	:	1164484028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PARK BRIAN MICKELSON DC

Provider Business Mailing Address
First Line	:	1314 W AVE J
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2936
Country	:	US
Telephone Number	:	661-945-4441
Fax Number	:	661-945-4442

Provider Business Practice Location Address
First Line	:	1314 W AVE J
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2936
Country	:	US
Telephone Number	:	661-945-4441
Fax Number	:	661-945-4442

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	07/08/2007

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