Provider Demographics
NPI:1649955774
Name:PARK, SEON SOO (LAC)
Entity type:Individual
Prefix:
First Name:SEON
Middle Name:SOO
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 HENRIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1210
Mailing Address - Country:US
Mailing Address - Phone:213-703-8439
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 211
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6509
Practice Address - Country:US
Practice Address - Phone:213-703-6939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14036171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist