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	315D00000X	Inpatient Hospice	451790	TX
2	251G00000X	Community Based Hospice Care Agency

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	:	1700083524
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
Country	:	US
Telephone Number	:	214-841-2825
Fax Number	:	214-273-9671

Provider Business Practice Location Address
First Line	:	4849 W LAWTHER DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-1879
Country	:	US
Telephone Number	:	214-841-2825
Fax Number	:	214-370-2830

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JENNIFER BROADWAY
Credential	:	RN
Telephone Number	:	214-841-2825

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	03/25/2026

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