Provider Demographics
NPI:1104371442
Name:CLINIC AT C. C. YOUNG
Entity Type:Organization
Organization Name:CLINIC AT C. C. YOUNG
Other - Org Name:COMMUNITY CLINIC AT C. C. YOUNG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CREWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-841-2819
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:
Practice Address - Street 1:4829 W LAWTHER DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-1858
Practice Address - Country:US
Practice Address - Phone:972-432-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX645300207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty