Healthcare Provider Details

I. General information

NPI: 1275558868
Provider Name (Legal Business Name): S & SONG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4616 MORNING RIDE CT
ELLICOTT CITY MD
21042
US

IV. Provider business mailing address

4616 MORNING RIDE CT
ELLICOTT CITY MD
21042
US

V. Phone/Fax

Practice location:
  • Phone: 410-829-5148
  • Fax: 410-462-3517
Mailing address:
  • Phone: 410-461-4425
  • Fax: 410-462-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR057717
License Number StateMD

VIII. Authorized Official

Name: MRS. SOONOK KONG SONG
Title or Position: PRESIDENT
Credential: CNS-PMM
Phone: 410-829-5148