=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396167789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOO HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2014
-----------------------------------------------------
Last Update Date | 01/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 WARNER AVE STE D
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-6461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-533-6699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 WARNER AVE STE D
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-6461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-533-6699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ACUPUNCTURIST
-----------------------------------------------------
Name | DR. KWAN WOO PARK
-----------------------------------------------------
Credential | L.AC. , DAOM
-----------------------------------------------------
Telephone | 949-533-6699
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC13245
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------