Provider Demographics
NPI:1699848788
Name:SONG, JAE SEON (LAC)
Entity Type:Individual
Prefix:
First Name:JAE SEON
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 VIKING AVE
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3821
Mailing Address - Country:US
Mailing Address - Phone:714-773-2692
Mailing Address - Fax:
Practice Address - Street 1:274 VIKING AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3821
Practice Address - Country:US
Practice Address - Phone:714-671-5994
Practice Address - Fax:714-671-5976
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11165171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist