Provider Demographics
NPI:1396187092
Name:SONG, CHUNG (REV DR)
Entity Type:Individual
Prefix:MR
First Name:CHUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:REV DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 W 6TH ST
Mailing Address - Street 2:STE 411
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3727 W 6TH ST
Practice Address - Street 2:STE 411
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-5105
Practice Address - Country:US
Practice Address - Phone:213-365-7400
Practice Address - Fax:213-201-3993
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker