Healthcare Provider Details

I. General information

NPI: 1710041447
Provider Name (Legal Business Name): BENJAMIN JINYOUNG SONG B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 15TH ST
SAN FRANCISCO CA
94116
US

IV. Provider business mailing address

111 RUSSIA AVE
SAN FRANCISCO CA
94112-2701
US

V. Phone/Fax

Practice location:
  • Phone: 415-682-3229
  • Fax:
Mailing address:
  • Phone: 909-816-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: