Basic Information
| Provider Information | |||||||||
| NPI: | 1326016437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JINGEU | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40000 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816587520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706683169 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 365 DILLON RIDGE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804356343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702620179 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12072 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.