Provider Demographics
NPI:1780656546
Name:PARK, JEONGPIL (DC)
Entity Type:Individual
Prefix:MR
First Name:JEONGPIL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MATTHEWS ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4866
Mailing Address - Country:US
Mailing Address - Phone:704-841-1701
Mailing Address - Fax:704-841-1596
Practice Address - Street 1:101 E MATTHEWS ST
Practice Address - Street 2:SUITE 700
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4866
Practice Address - Country:US
Practice Address - Phone:704-841-1701
Practice Address - Fax:704-841-1596
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902382Medicaid
NC2458023Medicare ID - Type UnspecifiedPERFORMING PROVIDER NUMBE
NC5902382Medicaid