Healthcare Provider Details

I. General information

NPI: 1215529698
Provider Name (Legal Business Name): ANNICE PARK RN, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HUNTINGTON DR STE 112
ARCADIA CA
91007-3478
US

IV. Provider business mailing address

301 W HUNTINGTON DR STE 112
ARCADIA CA
91007-3478
US

V. Phone/Fax

Practice location:
  • Phone: 626-461-5228
  • Fax:
Mailing address:
  • Phone: 626-461-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: