Provider Demographics
NPI:1700430519
Name:PARK, JAE MIN (DC)
Entity Type:Individual
Prefix:
First Name:JAE MIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 PLEASANT HILL RD STE 230
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5828
Mailing Address - Country:US
Mailing Address - Phone:678-924-3434
Mailing Address - Fax:
Practice Address - Street 1:1630 PLEASANT HILL RD STE 230
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5828
Practice Address - Country:US
Practice Address - Phone:678-924-3434
Practice Address - Fax:678-924-3432
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007440111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty