Provider Demographics
NPI:1669723938
Name:PARK, DEUL RAE
Entity type:Individual
Prefix:
First Name:DEUL RAE
Middle Name:
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 1:947 S ANAHEIM BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-5582
Mailing Address - Country:US
Mailing Address - Phone:657-208-1153
Mailing Address - Fax:657-208-1156
Practice Address - Street 1:947 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5582
Practice Address - Country:US
Practice Address - Phone:657-208-1153
Practice Address - Fax:657-208-1156
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14865171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist