Provider Demographics
NPI:1194896373
Name:PARK, JOSEPH (LAC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
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 1:134 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2922
Mailing Address - Country:US
Mailing Address - Phone:707-477-1597
Mailing Address - Fax:
Practice Address - Street 1:134 HOWARD ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2922
Practice Address - Country:US
Practice Address - Phone:707-477-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10287171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist