MEDICARE: DR. JUNGSUB PARK D.C.

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	111N00000X	Chiropractor	CHIR007138	GA

General Provider Information

NPI Number	:	1609993336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUNGSUB PARK D.C.

Provider Business Mailing Address
First Line	:	143 POWERS FERRY RD SE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-7557
Country	:	US
Telephone Number	:	770-509-5558
Fax Number	:

Provider Business Practice Location Address
First Line	:	143 POWERS FERRY RD SE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-7557
Country	:	US
Telephone Number	:	770-509-5558
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/09/2007

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