Healthcare Provider Details

I. General information

NPI: 1548385842
Provider Name (Legal Business Name): EUGENE PARK L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 W COMMONWEALTH AVE SUITE 101
FULLERTON CA
92833-2565
US

IV. Provider business mailing address

4128 W COMMONWEALTH AVE SUITE 101
FULLERTON CA
92833-2565
US

V. Phone/Fax

Practice location:
  • Phone: 714-879-7602
  • Fax:
Mailing address:
  • Phone: 714-879-7602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 6622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: