Provider Demographics
NPI:1659643351
Name:SONG, JIN OH (LAC)
Entity Type:Individual
Prefix:
First Name:JIN OH
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 ALAMEDA DE LAS PULGAS
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3508
Mailing Address - Country:US
Mailing Address - Phone:650-293-1777
Mailing Address - Fax:
Practice Address - Street 1:1080 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3508
Practice Address - Country:US
Practice Address - Phone:650-293-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13609171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13609OtherACUPUNCTURE LICENCE