Provider Demographics
NPI:1316438740
Name:SONG, JONG CHAN (LAC)
Entity type:Individual
Prefix:
First Name:JONG CHAN
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 S DOBSON RD STE 8
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6433
Mailing Address - Country:US
Mailing Address - Phone:480-314-0701
Mailing Address - Fax:
Practice Address - Street 1:2051 S DOBSON RD STE 8
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6433
Practice Address - Country:US
Practice Address - Phone:480-314-0701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0308171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist