Provider Demographics
NPI:1285404541
Name:PARK, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22570 FIRENZE ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3635
Mailing Address - Country:US
Mailing Address - Phone:310-351-0942
Mailing Address - Fax:
Practice Address - Street 1:22570 FIRENZE ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3635
Practice Address - Country:US
Practice Address - Phone:310-351-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker