Provider Demographics
NPI:1306333216
Name:PARK, SHIN
Entity type:Individual
Prefix:
First Name:SHIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:SHIN
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OMD
Mailing Address - Street 1:22478 DENKER AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-4223
Mailing Address - Country:US
Mailing Address - Phone:909-861-1015
Mailing Address - Fax:
Practice Address - Street 1:1385 S DIAMOND BAR BLVD
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2208
Practice Address - Country:US
Practice Address - Phone:909-861-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13533171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist