Healthcare Provider Details

I. General information

NPI: 1992925507
Provider Name (Legal Business Name): DR. AGATHA SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-6523
US

IV. Provider business mailing address

1450 NW MULHOLLAND DR # 156
ROSEBURG OR
97470-1942
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1377
  • Fax: 541-440-1394
Mailing address:
  • Phone: 620-802-1220
  • Fax: 541-673-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA04557700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: