MEDICARE: C C YOUNG MEMORIAL HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	110990	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043205479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C C YOUNG MEMORIAL HOME

Provider Business Mailing Address
First Line	:	4847 W LAWTHER DR
Second Line	:	SUITE #100
City	:	DALLAS
State	:	TX
Zip	:	75214-1853
Country	:	US
Telephone Number	:	214-827-8080
Fax Number	:	214-841-2890

Provider Business Practice Location Address
First Line	:	4849 W LAWTHER DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-1879
Country	:	US
Telephone Number	:	214-827-8080
Fax Number	:	214-370-2830

Authorized Official
Title or Position	:	ADMIN
Name	:	CATHERINE ANNE THOMAS
Credential	:	RN
Telephone Number	:	214-841-2825

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	04/04/2022

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