Organization
PROVIDENCE FOOT AND ANKLE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PETER SANG-WOOK PARK DPM (PODIATRIST/CEO)
(323) 732-7551
Entity
Organization
Contact information
Practice address
3130 W OLYMPIC BLVD, SUITE 170, LOS ANGELES, CA 90006-2484
(323) 732-7551
(323) 732-7829
Mailing address
1417 STEIN STRAUSS ST, FULLERTON, CA 92833-2159
(714) 797-3668
Taxonomy
Speciality
Code
Description
License number
State
261QP1100X
Podiatric Clinic/Center
Primary
E4031
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CE810Z
PTAN
CA
Enumeration date
08/03/2009
Last updated
03/28/2020
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