# PRO FORM SPORTS MEDICINE AND WELLNESS ASSOCIATES

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1235432972
- **Authorized official:** DR. TAE KEUN PARK MD (PARTNER)
- **Authorized official phone:** (646) 489-5640

## Contact information

- **Practice address:** 201 ROUTE 17, 11TH FLOOR, RUTHERFORD, NJ 07070-2574
- **Practice address phone:** (201) 549-8846
- **Practice address fax:** (201) 549-8839
- **Mailing address:** 201 ROUTE 17, 11TH FLOOR, RUTHERFORD, NJ 07070-2574
- **Mailing address phone:** (201) 549-8846
- **Mailing address fax:** (201) 549-8839

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207PS0010X | Sports Medicine (Emergency Medicine) Physician | 25MA08835000 | NJ | Yes |

## Other

- **Enumeration date:** 12/20/2010
- **Last updated:** 12/20/2010