Provider Demographics
NPI:1871781419
Name:PARK, HEUNG S (LAC)
Entity type:Individual
Prefix:
First Name:HEUNG
Middle Name:S
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 1:258 S OXFORD AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5172
Mailing Address - Country:US
Mailing Address - Phone:213-500-6162
Mailing Address - Fax:323-468-9536
Practice Address - Street 1:258 S OXFORD AVE STE 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-5172
Practice Address - Country:US
Practice Address - Phone:213-500-6162
Practice Address - Fax:323-468-9536
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6098171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0060980Medicaid