Provider Demographics
NPI:1730665142
Name:PARK, HYUNSOO (LAC)
Entity Type:Individual
Prefix:
First Name:HYUNSOO
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:EDDIE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:4 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2307
Mailing Address - Country:US
Mailing Address - Phone:201-421-7733
Mailing Address - Fax:
Practice Address - Street 1:1060 MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2592
Practice Address - Country:US
Practice Address - Phone:201-421-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00132300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist