Provider Demographics
NPI:1013260363
Name:PARK, JONGMOON (LAC)
Entity type:Individual
Prefix:
First Name:JONGMOON
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 1:500 S VIRGIL AVE
Mailing Address - Street 2:#302
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1404
Mailing Address - Country:US
Mailing Address - Phone:213-385-5356
Mailing Address - Fax:213-385-5318
Practice Address - Street 1:500 S VIRGIL AVE
Practice Address - Street 2:#302
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1404
Practice Address - Country:US
Practice Address - Phone:213-385-5356
Practice Address - Fax:213-385-5318
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14882171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist