Basic Information
| Provider Information | |||||||||
| NPI: | 1396187092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | CHUNG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | REV. DR. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3727 W 6TH ST | ||||||||
| Address2: | STE 411 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900205105 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3727 W 6TH ST | ||||||||
| Address2: | STE 411 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900205105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133657400 | ||||||||
| FaxNumber: | 2132013993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.