Organization
JEONG SIK PARK MD A PROF CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COLLEEN BRADRICK (MEDICAL BILLER)
(707) 994-8818
Entity
Organization
Contact information
Practice address
15250 LAKESHORE DR STE C, CLEARLAKE, CA 95422-8107
(707) 995-7077
Mailing address
PO BOX 6017, CLEARLAKE, CA 95422-6017
(707) 995-7077
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
A45408
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00A454080
—
CA
Enumeration date
07/02/2008
Last updated
07/02/2008
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