MEDICARE: MR. WILLIAM W EVERLY JR. CARE PROVIDER

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	253Z00000X	In Home Supportive Care Agency	002919919	CA
2	374U00000X	Home Health Aide	002919919	CA

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	:	1659078582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM W EVERLY JR. CARE PROVIDER

Provider Business Mailing Address
First Line	:	30051 SWAN POINT DR
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-7407
Country	:	US
Telephone Number	:	949-212-8851
Fax Number	:	949-481-3197

Provider Business Practice Location Address
First Line	:	30051 SWAN POINT DR
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-7407
Country	:	US
Telephone Number	:	949-212-8851
Fax Number	:	949-481-3197

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2023
Last Update Date	:	02/10/2023

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