MEDICARE: CLINIC AT C. C. YOUNG

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	207QA0505X	Adult Medicine Physician	645300	TX

General Provider Information

NPI Number	:	1104371442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINIC AT C. C. YOUNG

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	:

Provider Business Practice Location Address
First Line	:	4829 W LAWTHER DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-1858
Country	:	US
Telephone Number	:	972-432-7874
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	RUSSELL CREWS
Credential	:
Telephone Number	:	214-841-2819

Provider Enumeration Date	:	08/16/2016
Last Update Date	:	08/16/2016

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