Healthcare Provider Details

I. General information

NPI: 1952535270
Provider Name (Legal Business Name): SANG BOG PARK L,AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PENINSULA CTR STE D
ROLLING HILLS ESTATES CA
90274-3563
US

IV. Provider business mailing address

50 PENINSULA CTR STE D
ROLLING HILLS ESTATES CA
90274-3563
US

V. Phone/Fax

Practice location:
  • Phone: 310-541-7999
  • Fax: 310-544-1969
Mailing address:
  • Phone: 310-541-7999
  • Fax: 310-544-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC12201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: