Provider Demographics
NPI:1235992983
Name:SONG, DAESIG
Entity Type:Individual
Prefix:MR
First Name:DAESIG
Middle Name:
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 1:233 S LA FAYETTE PARK PL
Mailing Address - Street 2:301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-1336
Mailing Address - Country:US
Mailing Address - Phone:213-729-8166
Mailing Address - Fax:
Practice Address - Street 1:233 S LA FAYETTE PARK PL
Practice Address - Street 2:301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1336
Practice Address - Country:US
Practice Address - Phone:213-729-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19512171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist