Provider Demographics
NPI:1144537044
Name:SONG, JINHO (ACUPUNCTURIST)
Entity type:Individual
Prefix:
First Name:JINHO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CENTERPOINTE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1059
Mailing Address - Country:US
Mailing Address - Phone:714-887-4940
Mailing Address - Fax:
Practice Address - Street 1:12 CENTERPOINTE DR STE 104
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1059
Practice Address - Country:US
Practice Address - Phone:714-887-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13611171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD9972377OtherDRIVER LICENSE