Provider Demographics
NPI:1518331859
Name:PARK, JIN JOO
Entity Type:Individual
Prefix:
First Name:JIN JOO
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S BEACH BLVD
Mailing Address - Street 2:APT K1015
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-1103
Mailing Address - Country:US
Mailing Address - Phone:714-213-5171
Mailing Address - Fax:
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:SUITE 130
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:714-213-5171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16908171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist