Provider Demographics
NPI:1144512476
Name:PARK, KI CHAE (LAC DAOM)
Entity type:Individual
Prefix:
First Name:KI CHAE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:LAC DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 N PIEDRAS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-4210
Mailing Address - Country:US
Mailing Address - Phone:915-564-6100
Mailing Address - Fax:
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12934171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist