Healthcare Provider Details

I. General information

NPI: 1700512662
Provider Name (Legal Business Name): JI SON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-7009
  • Fax:
Mailing address:
  • Phone: 951-268-7009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA LONG
Title or Position: CREDENTIALING
Credential:
Phone: 501-223-2776