Provider Demographics
NPI:1356025472
Name:SONG, MIN SEON (LAC)
Entity type:Individual
Prefix:
First Name:MIN 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 1:1645 AMBERWOOD DR APT 28
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-1962
Mailing Address - Country:US
Mailing Address - Phone:323-330-7951
Mailing Address - Fax:
Practice Address - Street 1:9335 CHAPMAN AVENUE
Practice Address - Street 2:SUIT 108
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841
Practice Address - Country:US
Practice Address - Phone:714-636-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19664171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist