Provider Demographics
NPI:1225298805
Name:SONG, NICHOLAS SEUNG
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:SEUNG
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15101 E ILIFF AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-4543
Mailing Address - Country:US
Mailing Address - Phone:303-369-2882
Mailing Address - Fax:720-452-6296
Practice Address - Street 1:15101 E ILIFF AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-4543
Practice Address - Country:US
Practice Address - Phone:303-369-2882
Practice Address - Fax:720-452-6296
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11234171100000X
CO1604171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist