1144253030 NPI number — DR. LORIN B PARK O.D.

Table of content: DR. LORIN B PARK O.D. (NPI 1144253030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144253030 NPI number — DR. LORIN B PARK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
LORIN
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PARK
Provider Other First Name:
L
Provider Other Middle Name:
BRENDT
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144253030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5204 MATIA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASCO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99301-7888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-542-1151
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4820 N ROAD 68
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99301-9009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-543-7953
Provider Business Practice Location Address Fax Number:
509-543-7955
Provider Enumeration Date:
07/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1016TX , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)