Provider Demographics
NPI:1134703838
Name:SONG, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7740 GARVEY AVE # B100-102
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3077
Mailing Address - Country:US
Mailing Address - Phone:626-905-1464
Mailing Address - Fax:
Practice Address - Street 1:7740 GARVEY AVE # B100-102
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-3077
Practice Address - Country:US
Practice Address - Phone:626-905-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-09
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95235561163W00000X
CANP95025169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse