Provider Demographics
NPI:1972962223
Name:PARK, SEUNG (LAC)
Entity Type:Individual
Prefix:
First Name:SEUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9734 PLEASANT GATE LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-5494
Mailing Address - Country:US
Mailing Address - Phone:770-820-7163
Mailing Address - Fax:
Practice Address - Street 1:9734 PLEASANT GATE LN
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-5494
Practice Address - Country:US
Practice Address - Phone:770-820-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02238171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist