Provider Demographics
NPI:1699054577
Name:PARK, DANIEL ILWOO (LMP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ILWOO
Last Name:PARK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13524
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98082-1524
Mailing Address - Country:US
Mailing Address - Phone:425-890-5857
Mailing Address - Fax:
Practice Address - Street 1:15433 COUNTRY CLUB DR
Practice Address - Street 2:UNIT A206
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1260
Practice Address - Country:US
Practice Address - Phone:425-890-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60240620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist