=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215237888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHULHOON PARK L.AC.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2010
-----------------------------------------------------
Last Update Date | 10/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6242 BEACH BLVD STE B
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90621-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-810-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1420 STARBUCK ST
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-5670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-810-6259
-----------------------------------------------------
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 | AC13066
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------