Provider Demographics
NPI:1831425545
Name:PARK, MYUNG KYU (LAC)
Entity type:Individual
Prefix:MR
First Name:MYUNG
Middle Name:KYU
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 1:4671 EXPRESS DR N
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5562
Mailing Address - Country:US
Mailing Address - Phone:631-471-5570
Mailing Address - Fax:631-471-8470
Practice Address - Street 1:4671 EXPRESS DR N
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5562
Practice Address - Country:US
Practice Address - Phone:631-471-5570
Practice Address - Fax:631-471-8470
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001928171100000X
NY024328172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist