1700083524 NPI number — C.C. YOUNG MEMORIAL HOME

Table of content: (NPI 1700083524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700083524 NPI number — C.C. YOUNG MEMORIAL HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C.C. YOUNG MEMORIAL HOME
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:
6
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:
1700083524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4847 W. LAWTHER DR.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-841-2825
Provider Business Mailing Address Fax Number:
214-273-9671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4849 W LAWTHER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75214-1879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-841-2825
Provider Business Practice Location Address Fax Number:
214-370-2830
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
214-841-2825

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 315D00000X , with the licence number: 451790 , 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: 001013912 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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