Provider Demographics
NPI:1396104204
Name:SITI AND JIDO PARK FOUNDATION, INC
Entity type:Organization
Organization Name:SITI AND JIDO PARK FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-222-8528
Mailing Address - Street 1:1804 CORNELL LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-1727
Mailing Address - Country:US
Mailing Address - Phone:940-222-8528
Mailing Address - Fax:
Practice Address - Street 1:1804 CORNELL LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1727
Practice Address - Country:US
Practice Address - Phone:940-222-8528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251V00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251V00000XAgenciesVoluntary or Charitable