Provider Demographics
NPI:1033311634
Name:PARK, GRACE S (LAC, PHD)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7122 BON VILLA CIR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1167
Mailing Address - Country:US
Mailing Address - Phone:562-754-1005
Mailing Address - Fax:
Practice Address - Street 1:7122 BON VILLA CIR
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1167
Practice Address - Country:US
Practice Address - Phone:562-754-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9620171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist