Provider Demographics
NPI:1720586902
Name:PARK, YONG JOON CALEB
Entity Type:Individual
Prefix:
First Name:YONG JOON
Middle Name:CALEB
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11037 WARNER AVE # 339
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:949-253-4292
Practice Address - Street 1:11037 WARNER AVE # 339
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4007
Practice Address - Country:US
Practice Address - Phone:800-273-4292
Practice Address - Fax:949-253-4292
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other