Healthcare Provider Details

I. General information

NPI: 1831663145
Provider Name (Legal Business Name): CHONG HOON PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2019
Last Update Date: 01/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12425 CHERRYCREEK LN
CERRITOS CA
90703-2029
US

IV. Provider business mailing address

12425 CHERRYCREEK LN
CERRITOS CA
90703-2029
US

V. Phone/Fax

Practice location:
  • Phone: 714-318-2515
  • Fax:
Mailing address:
  • Phone: 714-318-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC18319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: