Provider Demographics
NPI:1275356974
Name:PARK, BO (OTD)
Entity type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 W SAHARA AVE APT 2053
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5385
Mailing Address - Country:US
Mailing Address - Phone:213-422-1955
Mailing Address - Fax:
Practice Address - Street 1:8020 W SAHARA AVE STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7917
Practice Address - Country:US
Practice Address - Phone:702-595-5437
Practice Address - Fax:702-425-2787
Is Sole Proprietor?:No
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOT-3580225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist