1043525231 NPI number — YOUNG CLINIC, PC

Table of content: (NPI 1043525231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043525231 NPI number — YOUNG CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUNG CLINIC, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043525231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2216 ROYAL LN
Provider Second Line Business Mailing Address:
STE 113
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75229-3309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-231-6152
Provider Business Mailing Address Fax Number:
972-243-2206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2216 ROYAL LN
Provider Second Line Business Practice Location Address:
STE 113
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75229-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-231-6152
Provider Business Practice Location Address Fax Number:
972-243-2206
Provider Enumeration Date:
08/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SIM
Authorized Official First Name:
YOUNGDONG
Authorized Official Middle Name:
Authorized Official Title or Position:
DC/OWNER
Authorized Official Telephone Number:
469-231-6152

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  10609 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1811161482 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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