Provider Demographics
NPI:1114580503
Name:PARK, JEONG SUN
Entity Type:Individual
Prefix:
First Name:JEONG SUN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 E IMPERIAL HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3226
Mailing Address - Country:US
Mailing Address - Phone:310-609-2827
Mailing Address - Fax:
Practice Address - Street 1:3150 E IMPERIAL HWY STE 200
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3226
Practice Address - Country:US
Practice Address - Phone:310-609-2827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist