Healthcare Provider Details

I. General information

NPI: 1013067131
Provider Name (Legal Business Name): SHINKWEON PARK L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 OLD NORCROSS RD STE 400
DULUTH GA
30096-4335
US

IV. Provider business mailing address

3705 OLD NORCROSS RD STE 400
DULUTH GA
30096-4335
US

V. Phone/Fax

Practice location:
  • Phone: 770-696-7460
  • Fax:
Mailing address:
  • Phone: 770-696-7460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC7613
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: