Provider Demographics
NPI:1528119534
Name:SONG, WON MOO (LAC)
Entity type:Individual
Prefix:MR
First Name:WON
Middle Name:MOO
Last Name:SONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19705 SHADOW GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3840
Mailing Address - Country:US
Mailing Address - Phone:818-590-4697
Mailing Address - Fax:
Practice Address - Street 1:17611 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3510
Practice Address - Country:US
Practice Address - Phone:818-343-7575
Practice Address - Fax:818-343-7272
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 6705171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist