Provider Demographics
NPI:1598835340
Name:PARK, RICHARD (AC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12131 BERTHA ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7520
Mailing Address - Country:US
Mailing Address - Phone:213-383-0007
Mailing Address - Fax:866-621-2931
Practice Address - Street 1:3407 W 6TH ST STE 617
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-2553
Practice Address - Country:US
Practice Address - Phone:213-383-0007
Practice Address - Fax:866-621-2931
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6341171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC6341OtherLICENSE NUMBER