Provider Demographics
NPI:1760749352
Name:PARK, JONG HO (LAC)
Entity Type:Individual
Prefix:MR
First Name:JONG
Middle Name:HO
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2707 S DIAMOND BAR BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3500
Mailing Address - Country:US
Mailing Address - Phone:909-598-8682
Mailing Address - Fax:
Practice Address - Street 1:2707 S DIAMOND BAR BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3500
Practice Address - Country:US
Practice Address - Phone:909-598-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5070171100000X
GA215171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist