Healthcare Provider Details

I. General information

NPI: 1073864831
Provider Name (Legal Business Name): SUNG HO PARK L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 WESTWOOD AVE STE 2
RIVER VALE NJ
07675-6375
US

IV. Provider business mailing address

688 WESTWOOD AVE STE 2
RIVER VALE NJ
07675-6375
US

V. Phone/Fax

Practice location:
  • Phone: 201-596-4040
  • Fax:
Mailing address:
  • Phone: 201-596-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01990
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number4265
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00072700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: