Provider Demographics
NPI:1659078582
Name:EVERLY, WILLIAM W JR (CARE PROVIDER)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:W
Last Name:EVERLY
Suffix:JR
Gender:M
Credentials:CARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30051 SWAN POINT DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7407
Mailing Address - Country:US
Mailing Address - Phone:949-212-8851
Mailing Address - Fax:949-481-3197
Practice Address - Street 1:30051 SWAN POINT DR
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-7407
Practice Address - Country:US
Practice Address - Phone:949-212-8851
Practice Address - Fax:949-481-3197
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA002919919253Z00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA002919919Medicaid