Provider Demographics
NPI:1366886160
Name:PARK, MI RAN (ACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:MI RAN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 FOOTHILL BLVD
Mailing Address - Street 2:2
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-2693
Mailing Address - Country:US
Mailing Address - Phone:818-249-5689
Mailing Address - Fax:818-249-5689
Practice Address - Street 1:3130 FOOTHILL BLVD
Practice Address - Street 2:2
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-2693
Practice Address - Country:US
Practice Address - Phone:818-249-5689
Practice Address - Fax:818-249-5689
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11653171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist