Healthcare Provider Details

I. General information

NPI: 1619521408
Provider Name (Legal Business Name): GAVIN YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 FILBERT ST
SAN FRANCISCO CA
94133-2760
US

IV. Provider business mailing address

729 FILBERT ST
SAN FRANCISCO CA
94133-2760
US

V. Phone/Fax

Practice location:
  • Phone: 415-352-2050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: