Provider Demographics
NPI:1609993336
Name:PARK, JUNGSUB (DC)
Entity Type:Individual
Prefix:DR
First Name:JUNGSUB
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 POWERS FERRY RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-7557
Mailing Address - Country:US
Mailing Address - Phone:770-509-5558
Mailing Address - Fax:
Practice Address - Street 1:143 POWERS FERRY RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7557
Practice Address - Country:US
Practice Address - Phone:770-509-5558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHLMMedicare ID - Type UnspecifiedCARRIER PROVIDER NUMBER
GAU97143Medicare UPIN