Provider Demographics
NPI:1568941003
Name:PARK, KYUNGJIN (LAC)
Entity Type:Individual
Prefix:
First Name:KYUNGJIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 DIMAS CT
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07640-1604
Mailing Address - Country:US
Mailing Address - Phone:201-446-3166
Mailing Address - Fax:
Practice Address - Street 1:215 OLD HOOK RD STE 3C
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3173
Practice Address - Country:US
Practice Address - Phone:201-383-9833
Practice Address - Fax:201-383-9263
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00119900171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist