Provider Demographics
NPI:1851702492
Name:SONG, EUN (LAC PHD)
Entity Type:Individual
Prefix:MRS
First Name:EUN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:LAC PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S SAN VICENTE BLVD
Mailing Address - Street 2:#420
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4667
Mailing Address - Country:US
Mailing Address - Phone:323-452-9555
Mailing Address - Fax:323-452-9550
Practice Address - Street 1:640 S SAN VICENTE BLVD #420
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4667
Practice Address - Country:US
Practice Address - Phone:323-452-9555
Practice Address - Fax:323-452-9550
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist