Provider Demographics
NPI:1639312267
Name:YOUNG, JOHN CHARLES WAVERLY
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES WAVERLY
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6848 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2857
Mailing Address - Country:US
Mailing Address - Phone:951-341-8830
Mailing Address - Fax:951-682-2561
Practice Address - Street 1:6848 MAGNOLIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2857
Practice Address - Country:US
Practice Address - Phone:951-341-8830
Practice Address - Fax:951-682-2561
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator