Provider Demographics
NPI:1255145835
Name:PARK, VIVIAN SEONGHWA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:SEONGHWA
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 GUNSTON PLZ UNIT 1417
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22199-8066
Mailing Address - Country:US
Mailing Address - Phone:240-481-8779
Mailing Address - Fax:
Practice Address - Street 1:7726 GUNSTON PLZ UNIT 1417
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22199-8066
Practice Address - Country:US
Practice Address - Phone:240-481-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
VA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier