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NPI Code Detail

MEDICARE: JAE HWAN SONG ATC

MEDICARE: JAE HWAN SONG ATC
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
12255A2300XAthletic TrainerAL3738FL

General Provider Information

NPI Number : 1265823421
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAE HWAN SONG ATC
Provider Business Mailing Address
First Line : 1400 HANCOCK BLVD APT 1312
Second Line :
City : DAYTONA BEACH
State : FL
Zip : 32114-5636
Country : US
Telephone Number : 619-886-6597
Fax Number :
Provider Business Practice Location Address
First Line : 640 DR MARY MCLEOD BETHUNE BLVD
Second Line : HANDFILED ATHLETIC TRAINING CENTER
City : DAYTONA BEACH
State : FL
Zip : 32114-3012
Country : US
Telephone Number : 386-481-2261
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/10/2015
Last Update Date : 02/10/2015

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