Healthcare Provider Details

I. General information

NPI: 1023199924
Provider Name (Legal Business Name): JAE YOUNG PARK ACUPUNCTURIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD BLDG 3006TH INTERDISCIPLINARY PAIN MANAGEMENT CENTER
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

300 HOSPITAL RD INTERDISCIPLINARY PAIN MANAGEMENT CENTER
FORT GORDON GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-0716
  • Fax: 706-787-0196
Mailing address:
  • Phone: 706-787-8322
  • Fax: 706-787-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number11226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: