Provider Demographics
NPI:1306552195
Name:PARK, KENNETH (DACM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:DACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W 36TH ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-9776
Mailing Address - Country:US
Mailing Address - Phone:201-424-4263
Mailing Address - Fax:
Practice Address - Street 1:8 W 36TH ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-9776
Practice Address - Country:US
Practice Address - Phone:201-424-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25NZ00137300171100000X
NY005964171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist