Provider Demographics
NPI:1861649881
Name:PARK, JAE HYUN
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:HYUN
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 1:3020 WILSHIRE BLVD STE 222
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1146
Mailing Address - Country:US
Mailing Address - Phone:213-389-3003
Mailing Address - Fax:
Practice Address - Street 1:3020 WILSHIRE BLVD STE 222
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010
Practice Address - Country:US
Practice Address - Phone:213-389-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-20
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11917171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist