Provider Demographics
NPI:1285975128
Name:IL HWAN PARK CHIROPRACTIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:IL HWAN PARK CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IL HWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-249-0422
Mailing Address - Street 1:4155 MOORPARK AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1714
Mailing Address - Country:US
Mailing Address - Phone:408-249-0422
Mailing Address - Fax:408-249-0430
Practice Address - Street 1:4155 MOORPARK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1714
Practice Address - Country:US
Practice Address - Phone:408-249-0422
Practice Address - Fax:408-249-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFW107AMedicare PIN