1003071887 NPI number — WILLIAM L PARK, OD, LLC

Table of content: (NPI 1003071887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003071887 NPI number — WILLIAM L PARK, OD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM L PARK, OD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003071887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67203-3601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-440-1690
Provider Business Mailing Address Fax Number:
316-440-1695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67203-3601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-440-1690
Provider Business Practice Location Address Fax Number:
316-440-1695
Provider Enumeration Date:
07/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
316-440-1690

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  1798 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1798 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: KA1156 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com