Healthcare Provider Details

I. General information

NPI: 1750377578
Provider Name (Legal Business Name): JAMES OLIN YOUNG JR. C.P.,F.A.A.O.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERCER UNIVERSITY DR
MACON GA
31210-6239
US

IV. Provider business mailing address

802 20TH ST E
TIFTON GA
31794-3645
US

V. Phone/Fax

Practice location:
  • Phone: 478-474-5678
  • Fax: 478-474-5018
Mailing address:
  • Phone: 229-387-6600
  • Fax: 229-387-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCP002910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: