Provider Demographics
NPI:1740585751
Name:SONG, KEEWOON (LAC)
Entity Type:Individual
Prefix:MR
First Name:KEEWOON
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 1:3337 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-2321
Mailing Address - Country:US
Mailing Address - Phone:323-730-8890
Mailing Address - Fax:323-730-8890
Practice Address - Street 1:3337 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-2321
Practice Address - Country:US
Practice Address - Phone:323-730-8890
Practice Address - Fax:323-730-8890
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-22
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6048171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist