1730445313 NPI number — SONG PLASTIC SURGERY, INC.

Table of content: (NPI 1730445313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730445313 NPI number — SONG PLASTIC SURGERY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SONG PLASTIC SURGERY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730445313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4968 BOOTH CIR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92604-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-701-4454
Provider Business Mailing Address Fax Number:
949-701-4878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4968 BOOTH CIR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92604-3360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-701-4454
Provider Business Practice Location Address Fax Number:
949-701-4878
Provider Enumeration Date:
04/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SONG
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
OWNER / PRINCIPAL
Authorized Official Telephone Number:
949-701-4454

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  A102406 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GA903A . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: CK861T . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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