Provider Demographics
NPI:1184849473
Name:PARK, KI TAEK (LICAC OMD)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:TAEK
Last Name:PARK
Suffix:
Gender:M
Credentials:LICAC OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4943 LA PALMA AVE
Mailing Address - Street 2:SUITE D.
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-2054
Mailing Address - Country:US
Mailing Address - Phone:562-402-2003
Mailing Address - Fax:562-402-0363
Practice Address - Street 1:4943 LA PALMA AVE
Practice Address - Street 2:SUITE D.
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-2054
Practice Address - Country:US
Practice Address - Phone:562-402-2003
Practice Address - Fax:562-402-0363
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 3451171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist