Provider Demographics
NPI:1417236415
Name:PARK, SUNGMIN (LAC)
Entity Type:Individual
Prefix:MR
First Name:SUNGMIN
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 1:2201 W BROADWAY APT B108
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2386
Mailing Address - Country:US
Mailing Address - Phone:714-653-3434
Mailing Address - Fax:
Practice Address - Street 1:3400 W BALL RD STE 101A
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3735
Practice Address - Country:US
Practice Address - Phone:714-828-8234
Practice Address - Fax:714-828-8237
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12781171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist