Provider Demographics
NPI:1861595951
Name:PARK, CHANG-GYU (DC)
Entity type:Individual
Prefix:MR
First Name:CHANG-GYU
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:18361 BEAR VALLEY RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345
Mailing Address - Country:US
Mailing Address - Phone:760-948-0353
Mailing Address - Fax:760-948-0354
Practice Address - Street 1:18361 BEAR VALLEY RD
Practice Address - Street 2:SUITE 6
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345
Practice Address - Country:US
Practice Address - Phone:760-948-0353
Practice Address - Fax:760-948-0354
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25780111N00000X
CAAC7022171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0257800Medicare ID - Type Unspecified