Provider Demographics
NPI:1275178055
Name:PARK, SE RYUNG
Entity Type:Individual
Prefix:
First Name:SE
Middle Name:RYUNG
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 1:15541 WILLIAMS ST APT D4
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4191
Mailing Address - Country:US
Mailing Address - Phone:714-902-5959
Mailing Address - Fax:
Practice Address - Street 1:15541 WILLIAMS ST APT D4
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4191
Practice Address - Country:US
Practice Address - Phone:714-902-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11324171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist