Provider Demographics
NPI:1770662181
Name:SONG, SIMON KI (DOM)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:KI
Last Name:SONG
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:MR
Other - First Name:KI SOO
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOM
Mailing Address - Street 1:2601 N. DEL ROSA AVE.
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-474-9108
Mailing Address - Fax:310-976-8788
Practice Address - Street 1:2601 N. DEL ROSA AVE.
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-474-9108
Practice Address - Fax:310-376-8788
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 7495171100000X
CA7495171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist