Healthcare Provider Details

I. General information

NPI: 1346572377
Provider Name (Legal Business Name): DONG WOO PARK L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W REDONDO BEACH BLVD SUITE111
GARDENA CA
90248-1612
US

IV. Provider business mailing address

555 W REDONDO BEACH BLVD SUITE111
GARDENA CA
90248-1612
US

V. Phone/Fax

Practice location:
  • Phone: 310-756-0001
  • Fax: 310-756-0004
Mailing address:
  • Phone: 310-756-0001
  • Fax: 310-756-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC8057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: