Healthcare Provider Details

I. General information

NPI: 1285984120
Provider Name (Legal Business Name): MS. SANDRA SUNGJU PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WATERSIDE DR
LITTLE FERRY NJ
07643-2208
US

IV. Provider business mailing address

103 WATERSIDE DR
LITTLE FERRY NJ
07643-2208
US

V. Phone/Fax

Practice location:
  • Phone: 201-741-7578
  • Fax:
Mailing address:
  • Phone: 201-741-7578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00092100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00277700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: