Provider Demographics
NPI:1043205479
Name:C C YOUNG MEMORIAL HOME
Entity Type:Organization
Organization Name:C C YOUNG MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:214-841-2825
Mailing Address - Street 1:4847 W LAWTHER DR
Mailing Address - Street 2:SUITE #100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1853
Mailing Address - Country:US
Mailing Address - Phone:214-827-8080
Mailing Address - Fax:214-841-2890
Practice Address - Street 1:4849 W LAWTHER DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-1879
Practice Address - Country:US
Practice Address - Phone:214-827-8080
Practice Address - Fax:214-370-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110990314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000464001Medicaid
TX000464001Medicaid