Provider Demographics
NPI:1013067131
Name:PARK, SHINKWEON (LAC)
Entity Type:Individual
Prefix:
First Name:SHINKWEON
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 1:3705 OLD NORCROSS RD
Mailing Address - Street 2:STE 400
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4335
Mailing Address - Country:US
Mailing Address - Phone:770-696-7460
Mailing Address - Fax:
Practice Address - Street 1:3705 OLD NORCROSS RD
Practice Address - Street 2:STE 400
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4335
Practice Address - Country:US
Practice Address - Phone:770-696-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7613171100000X
GA236171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist