1184902231 NPI number — MS. JIN HEE PARK L.AC.

Table of content: KRYSTEL RAE ROGERS (NPI 1659093029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184902231 NPI number — MS. JIN HEE PARK L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JIN HEE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
F

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:
1184902231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11064 W OCEAN AIR DR APT 126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92130-4600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-229-6842
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7339 EL CAJON BLVD STE M
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-7435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-229-6842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2011

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:  14137 , 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)