Provider Demographics
NPI:1972744845
Name:PARK, IN KI (LAC)
Entity Type:Individual
Prefix:
First Name:IN KI
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:KELVIN
Other - Middle Name:IN KI
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:269 S. LA FAYETTE PARK PL STE 449
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057
Mailing Address - Country:US
Mailing Address - Phone:213-604-0081
Mailing Address - Fax:714-522-8775
Practice Address - Street 1:269 S LA FAYETTE PARK PL APT 449
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1378
Practice Address - Country:US
Practice Address - Phone:213-604-0081
Practice Address - Fax:714-522-8775
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10003171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist