Provider Demographics
NPI:1174699763
Name:PARK, CHANG SIK (L AC)
Entity type:Individual
Prefix:MR
First Name:CHANG
Middle Name:SIK
Last Name:PARK
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E THOUSAND OAKS BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8150
Mailing Address - Country:US
Mailing Address - Phone:805-495-0360
Mailing Address - Fax:805-495-2707
Practice Address - Street 1:100 E THOUSAND OAKS BLVD STE 250
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8150
Practice Address - Country:US
Practice Address - Phone:805-495-0360
Practice Address - Fax:805-495-2707
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3907171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0770272019OtherEMPLOYER IDENTIFICATION #