Provider Demographics
NPI:1376763623
Name:PARK, TAESUN (LAC)
Entity Type:Individual
Prefix:MR
First Name:TAESUN
Middle Name:
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 1:5441 BUFORD HWY
Mailing Address - Street 2:STE 202
Mailing Address - City:DARAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-1168
Mailing Address - Country:US
Mailing Address - Phone:770-451-7848
Mailing Address - Fax:
Practice Address - Street 1:5441 BUFORD HWY NE # SUIT202
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1124
Practice Address - Country:US
Practice Address - Phone:404-488-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA125171100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA125OtherACUPUNCTURE LICENSE NUMBE