Provider Demographics
NPI:1316154115
Name:SONG, CHUYOUN (LAC)
Entity type:Individual
Prefix:
First Name:CHUYOUN
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 1:6332 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2032
Mailing Address - Country:US
Mailing Address - Phone:951-276-0012
Mailing Address - Fax:951-276-0036
Practice Address - Street 1:555 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-1612
Practice Address - Country:US
Practice Address - Phone:310-323-9001
Practice Address - Fax:310-756-0004
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10654171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASONAMUACUMedicare UPIN