Provider Demographics
NPI:1477832459
Name:PARK, LEE SEOB (DC)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:SEOB
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:LEE SEOB
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:14701 LEE HWY
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2137
Mailing Address - Country:US
Mailing Address - Phone:703-543-4810
Mailing Address - Fax:703-543-4811
Practice Address - Street 1:14701 LEE HWY
Practice Address - Street 2:SUITE 307
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2137
Practice Address - Country:US
Practice Address - Phone:703-543-4810
Practice Address - Fax:703-543-4811
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor