Provider Demographics
NPI:1548337587
Name:PARK, WILSON C (DC)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:C
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 WESTWOOD BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4145
Mailing Address - Country:US
Mailing Address - Phone:310-869-0536
Mailing Address - Fax:310-441-3727
Practice Address - Street 1:2940 WESTWOOD BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4145
Practice Address - Country:US
Practice Address - Phone:310-869-0536
Practice Address - Fax:310-441-3727
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC251660OtherBLUE SHIELD OF CALIFORNIA
CA562422099OtherTAX ID NUMBER