Provider Demographics
NPI:1124169958
Name:SOUTH BAYLO UNIVERSITY
Entity type:Organization
Organization Name:SOUTH BAYLO UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTAND CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-533-1495
Mailing Address - Street 1:1126 N BROOKHURST ST
Mailing Address - Street 2:STE.#301
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1702
Mailing Address - Country:US
Mailing Address - Phone:714-535-3886
Mailing Address - Fax:714-535-3919
Practice Address - Street 1:1126 N BROOKHURST ST
Practice Address - Street 2:STE.#301
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1702
Practice Address - Country:US
Practice Address - Phone:714-535-3886
Practice Address - Fax:714-535-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283-2036-4171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty