Provider Demographics
NPI:1871602565
Name:SWANN SONG LLC
Entity type:Organization
Organization Name:SWANN SONG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONJA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-272-5543
Mailing Address - Street 1:11805 N CASSIOPEIA DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-3410
Mailing Address - Country:US
Mailing Address - Phone:520-272-5543
Mailing Address - Fax:520-579-3207
Practice Address - Street 1:11805 N CASSIOPEIA DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-3410
Practice Address - Country:US
Practice Address - Phone:520-272-5543
Practice Address - Fax:520-579-3207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20084710133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty