Provider Demographics
NPI:1639541485
Name:PARK, CHAN KYU (DC)
Entity Type:Individual
Prefix:
First Name:CHAN KYU
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 1:6630 MCGINNIS FERRY RD STE B
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1563
Mailing Address - Country:US
Mailing Address - Phone:678-473-0552
Mailing Address - Fax:678-473-0656
Practice Address - Street 1:6630 MCGINNIS FERRY RD
Practice Address - Street 2:SUITE B
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2164
Practice Address - Country:US
Practice Address - Phone:678-473-0552
Practice Address - Fax:678-473-0656
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009022111NR0400X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1588908685OtherGROUP NPI