Provider Demographics
NPI:1083828594
Name:PARK, HYUNG HO (LAC)
Entity Type:Individual
Prefix:
First Name:HYUNG HO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21209 BLOOMFIELD AVE
Mailing Address - Street 2:#10
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-2368
Mailing Address - Country:US
Mailing Address - Phone:562-865-6092
Mailing Address - Fax:
Practice Address - Street 1:3000 WILSHIRE BLVD
Practice Address - Street 2:#210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1136
Practice Address - Country:US
Practice Address - Phone:626-965-9385
Practice Address - Fax:626-965-1132
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10719171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 0107190Medicaid