Provider Demographics
NPI:1124291018
Name:PARK, JUNG MIN (LIC AC)
Entity type:Individual
Prefix:
First Name:JUNG MIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2685 S DAYTON WAY
Mailing Address - Street 2:#306
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-3958
Mailing Address - Country:US
Mailing Address - Phone:720-244-8512
Mailing Address - Fax:
Practice Address - Street 1:2685 S DAYTON WAY
Practice Address - Street 2:#306
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-3958
Practice Address - Country:US
Practice Address - Phone:720-244-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1743171100000X
CO2933246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No171100000XOther Service ProvidersAcupuncturist