1487036380 NPI number — GEORGE YOUNG III

Table of content: GEORGE YOUNG III (NPI 1487036380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487036380 NPI number — GEORGE YOUNG III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
GEORGE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

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:
1487036380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 E WALNUT ST
Provider Second Line Business Mailing Address:
PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91188-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-608-0044
Provider Business Mailing Address Fax Number:
877-514-0903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26926 CHERRY HILLS BLVD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENIFEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92586-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-216-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW66395 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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