=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174061956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEUNG K. PARK LAC, LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2017
-----------------------------------------------------
Last Update Date | 03/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 E 35TH ST #1E
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-3887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-285-7837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1106 128TH ST
-----------------------------------------------------
City | COLLEGE POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11356-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-285-7837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 005909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 015929
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------