Healthcare Provider Details

I. General information

NPI: 1639541485
Provider Name (Legal Business Name): CHAN KYU PARK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6630 MCGINNIS FERRY RD SUITE B
JOHNS CREEK GA
30097-2164
US

IV. Provider business mailing address

6630 MCGINNIS FERRY RD STE B
JOHNS CREEK GA
30097-1563
US

V. Phone/Fax

Practice location:
  • Phone: 678-473-0552
  • Fax: 678-473-0656
Mailing address:
  • Phone: 678-473-0552
  • Fax: 678-473-0656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR009022
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIR009022
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCHIR009022
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: