Provider Demographics
NPI:1710273156
Name:PARK, TAE SOOK (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:SOOK
Last Name:PARK
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S. CRENSHAW BLVD
Mailing Address - Street 2:302
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:323-938-1000
Mailing Address - Fax:
Practice Address - Street 1:903 S. CRENSHAW BLVD
Practice Address - Street 2:302
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019
Practice Address - Country:US
Practice Address - Phone:323-938-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12307171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist