Provider Demographics
NPI:1053089482
Name:SONG, KYEONGTAK (PHD, ATC)
Entity Type:Individual
Prefix:DR
First Name:KYEONGTAK
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 POLO CLUB BLVD UNIT 305
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8362
Mailing Address - Country:US
Mailing Address - Phone:704-497-0894
Mailing Address - Fax:
Practice Address - Street 1:720 SPORTS CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506-0001
Practice Address - Country:US
Practice Address - Phone:859-323-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer