Provider Demographics
NPI:1619204120
Name:PARK, SOON (ACUPUNCTURIST)
Entity Type:Individual
Prefix:MR
First Name:SOON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9773 SIERRA AVE # H7
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6716
Mailing Address - Country:US
Mailing Address - Phone:909-829-2349
Mailing Address - Fax:909-829-2349
Practice Address - Street 1:9773 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6716
Practice Address - Country:US
Practice Address - Phone:909-829-2349
Practice Address - Fax:909-829-2349
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALAC12047171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist