Provider Demographics
NPI:1326514423
Name:PARK, SE-MIN JOHN (LAC)
Entity Type:Individual
Prefix:
First Name:SE-MIN
Middle Name:JOHN
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 1:44150 W 12 MILE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2649
Mailing Address - Country:US
Mailing Address - Phone:248-238-8390
Mailing Address - Fax:
Practice Address - Street 1:44150 W 12 MILE RD STE 300
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2649
Practice Address - Country:US
Practice Address - Phone:248-238-8390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5402000102171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty