Provider Demographics
NPI:1215529698
Name:PARK, ANNICE (RN, LAC)
Entity type:Individual
Prefix:
First Name:ANNICE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W HUNTINGTON DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3478
Mailing Address - Country:US
Mailing Address - Phone:626-461-5228
Mailing Address - Fax:
Practice Address - Street 1:301 W HUNTINGTON DR STE 112
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3478
Practice Address - Country:US
Practice Address - Phone:626-461-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18934171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty