=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790291573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HONG-LIM PARK DIPL. OM, LAC, OMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2017
-----------------------------------------------------
Last Update Date | 12/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 BAY VIEW RD STE E
-----------------------------------------------------
City | MUKWONAGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53149-1770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-749-0939
-----------------------------------------------------
Fax | 262-749-0939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 N MAIN ST
-----------------------------------------------------
City | NORTH PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53153-9790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-749-0939
-----------------------------------------------------
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 | 421-55
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------