Provider Demographics
NPI:1245592211
Name:PARK, SEONG KEUN (LAC)
Entity Type:Individual
Prefix:
First Name:SEONG
Middle Name:KEUN
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 1:1790 ATKINSON RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7989
Mailing Address - Country:US
Mailing Address - Phone:770-936-0631
Mailing Address - Fax:770-936-0631
Practice Address - Street 1:1790 ATKINSON RD.
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7989
Practice Address - Country:US
Practice Address - Phone:770-936-0631
Practice Address - Fax:770-936-0631
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA188171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist