Provider Demographics
NPI:1508525379
Name:PARK, JAEWOONG (LAC)
Entity Type:Individual
Prefix:
First Name:JAEWOONG
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 1:1204 S BRISTOL ST # D7
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-3422
Mailing Address - Country:US
Mailing Address - Phone:714-232-3372
Mailing Address - Fax:
Practice Address - Street 1:1204 S BRISTOL ST # D7
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-3422
Practice Address - Country:US
Practice Address - Phone:714-232-3372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19271OtherACUPUNCTURE