Provider Demographics
NPI:1528019346
Name:YOUNGBLOOD, WILLIAM MANLY JR (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MANLY
Last Name:YOUNGBLOOD
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7187
Mailing Address - Country:US
Mailing Address - Phone:843-225-5855
Mailing Address - Fax:843-225-0355
Practice Address - Street 1:811 A ST. ANDREWS BLVD.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-225-5855
Practice Address - Fax:843-225-0355
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2039111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU67729Medicare UPIN