1023199924 NPI number — DR. JAE YOUNG PARK ACUPUNCTURIST

Table of content: DR. JAE YOUNG PARK ACUPUNCTURIST (NPI 1023199924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023199924 NPI number — DR. JAE YOUNG PARK ACUPUNCTURIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JAE
Provider Middle Name:
YOUNG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ACUPUNCTURIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023199924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 HOSPITAL RD
Provider Second Line Business Mailing Address:
INTERDISCIPLINARY PAIN MANAGEMENT CENTER
Provider Business Mailing Address City Name:
FORT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905-5741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-787-8322
Provider Business Mailing Address Fax Number:
706-787-0196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W HOSPITAL RD BLDG 3006TH
Provider Second Line Business Practice Location Address:
INTERDISCIPLINARY PAIN MANAGEMENT CENTER
Provider Business Practice Location Address City Name:
FORT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-5741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-787-0716
Provider Business Practice Location Address Fax Number:
706-787-0196
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  11226 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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