Healthcare Provider Details

I. General information

NPI: 1255463675
Provider Name (Legal Business Name): JAE CHANG PARK L.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 E MAIN ST
SANTA MARIA CA
93454-5331
US

IV. Provider business mailing address

940 E MAIN ST
SANTA MARIA CA
93454-5331
US

V. Phone/Fax

Practice location:
  • Phone: 805-332-9839
  • Fax:
Mailing address:
  • Phone: 805-332-9839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 10209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: