Provider Demographics
NPI:1588966063
Name:PARK, CHANJOON (LAC)
Entity type:Individual
Prefix:
First Name:CHANJOON
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 1:905 S EUCLID ST #111
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832
Mailing Address - Country:US
Mailing Address - Phone:714-446-9114
Mailing Address - Fax:562-299-5912
Practice Address - Street 1:905 S EUCLID ST #111
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832
Practice Address - Country:US
Practice Address - Phone:714-446-9114
Practice Address - Fax:562-299-5912
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12692171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC12692OtherACUPUNCTURE