MEDICARE: DONGKYU SONG L.AC DAOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC9686	CA
2	171100000X	Acupuncturist	OM000100	PA
3	171100000X	Acupuncturist	CQ-0000023	DE

General Provider Information

NPI Number	:	1114196276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONGKYU SONG L.AC DAOM

Provider Business Mailing Address
First Line	:	249 PHILADELPHIA PIKE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19809-3109
Country	:	US
Telephone Number	:	302-482-3025
Fax Number	:	302-476-8176

Provider Business Practice Location Address
First Line	:	249 PHILADELPHIA PIKE
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19809-3109
Country	:	US
Telephone Number	:	302-482-3025
Fax Number	:	302-476-8176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2008
Last Update Date	:	04/16/2018

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