Provider Demographics
NPI:1134559164
Name:SONG, JOHN KYU
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KYU
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W 2ND AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-6003
Mailing Address - Country:US
Mailing Address - Phone:509-768-0366
Mailing Address - Fax:
Practice Address - Street 1:9825 N INDIAN TRAIL RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-9359
Practice Address - Country:US
Practice Address - Phone:509-768-0366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000284171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist