Healthcare Provider Details

I. General information

NPI: 1659078582
Provider Name (Legal Business Name): WILLIAM W EVERLY JR. CARE PROVIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30051 SWAN POINT DR
CANYON LAKE CA
92587-7407
US

IV. Provider business mailing address

30051 SWAN POINT DR
CANYON LAKE CA
92587-7407
US

V. Phone/Fax

Practice location:
  • Phone: 949-212-8851
  • Fax: 949-481-3197
Mailing address:
  • Phone: 949-212-8851
  • Fax: 949-481-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number002919919
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number002919919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: