Provider Demographics
NPI:1669510228
Name:PARK, YONGEUL (LAC)
Entity Type:Individual
Prefix:
First Name:YONGEUL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6511
Mailing Address - Country:US
Mailing Address - Phone:213-382-2040
Mailing Address - Fax:213-382-6052
Practice Address - Street 1:3003 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6511
Practice Address - Country:US
Practice Address - Phone:213-382-2040
Practice Address - Fax:213-382-6052
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6330171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0063330Medicaid