MEDICARE: DR. JOOSUNG PARK D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	0104556083	VA

General Provider Information

NPI Number	:	1164504916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOOSUNG PARK D.C.

Provider Business Mailing Address
First Line	:	5900 CENTREVILLE RD. STE 205
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20121
Country	:	US
Telephone Number	:	703-378-1678
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 CENTREVILLE RD STE 205
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20121-2425
Country	:	US
Telephone Number	:	703-378-1678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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