Provider Demographics
NPI:1508404492
Name:PARK, CHAN JIN (LAC)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:JIN
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 1:21537 48TH AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1359
Mailing Address - Country:US
Mailing Address - Phone:347-549-2275
Mailing Address - Fax:
Practice Address - Street 1:21537 48TH AVE APT 2B
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-1359
Practice Address - Country:US
Practice Address - Phone:347-549-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5471171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist