Healthcare Provider Details

I. General information

NPI: 1245421809
Provider Name (Legal Business Name): CHARLES A YOUMANS CADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NE 4TH ST
PRINEVILLE OR
97754-1925
US

IV. Provider business mailing address

205 NE 4TH ST
PRINEVILLE OR
97754-1925
US

V. Phone/Fax

Practice location:
  • Phone: 541-416-1095
  • Fax: 541-416-0991
Mailing address:
  • Phone: 541-416-1095
  • Fax: 541-416-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5-11-75
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: