Provider Demographics
NPI:1134309891
Name:PARK, CHANG W
Entity Type:Individual
Prefix:
First Name:CHANG
Middle Name:W
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 1:975 S VERMONT AVE
Mailing Address - Street 2:SUITE #201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5906
Mailing Address - Country:US
Mailing Address - Phone:213-383-2726
Mailing Address - Fax:
Practice Address - Street 1:975 S VERMONT AVE
Practice Address - Street 2:SUITE #201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5906
Practice Address - Country:US
Practice Address - Phone:213-383-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-11
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC142171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist