Provider Demographics
NPI:1730651795
Name:PARK, KUN DONG (LAC)
Entity Type:Individual
Prefix:MR
First Name:KUN DONG
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 1:555 W REDONDO BEACH BLVD # 191
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-1612
Mailing Address - Country:US
Mailing Address - Phone:818-606-4733
Mailing Address - Fax:
Practice Address - Street 1:555 W REDONDO BEACH BLVD # 191
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-1612
Practice Address - Country:US
Practice Address - Phone:818-606-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16479171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty