MEDICARE: MR. SUNGMIN PARK L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC12781	CA

General Provider Information

NPI Number	:	1417236415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SUNGMIN PARK L.AC.

Provider Business Mailing Address
First Line	:	2201 W BROADWAY APT B108
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-2386
Country	:	US
Telephone Number	:	714-653-3434
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 W BALL RD STE 101A
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3735
Country	:	US
Telephone Number	:	714-828-8234
Fax Number	:	714-828-8237

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2011
Last Update Date	:	10/15/2013

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