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General NPI Number Information
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NPI Number | 1275962623
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Entity Type | Organization
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Legal Business Name | YOUNGVAX
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 606 HOGAN ALLEY DR
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City | MANSFIELD
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State | TX
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Zip | 76063-5473
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Country | US
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Telephone | 817-703-9375
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Fax |
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Provider Business Mailing Address
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Address Line | 606 HOGAN ALLEY DR
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City | MANSFIELD
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State | TX
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Zip | 76063-5473
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | SHAWNDRA YOUNG
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Credential |
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Telephone | 817-703-9375
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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