Provider Demographics
NPI:1386705614
Name:PARK, JAE SEOG
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:SEOG
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 SAN MIGUEL CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2816
Mailing Address - Country:US
Mailing Address - Phone:714-875-5533
Mailing Address - Fax:
Practice Address - Street 1:17450 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6262
Practice Address - Country:US
Practice Address - Phone:760-493-2929
Practice Address - Fax:760-493-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5537171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist