Provider Demographics
NPI:1780836031
Name:PARK, JINWOO
Entity Type:Individual
Prefix:
First Name:JINWOO
Middle Name:
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 1:4001 S LA COSTA CT
Mailing Address - Street 2:4001 S LA COSTA CT
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2037
Mailing Address - Country:US
Mailing Address - Phone:714-366-3062
Mailing Address - Fax:
Practice Address - Street 1:4001 S LA COSTA CT
Practice Address - Street 2:4001 S LA COSTA CT
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:714-366-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12466171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist