Provider Demographics
NPI:1710097407
Name:YOUNG, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2525 KANEVILLE RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2575
Practice Address - Country:US
Practice Address - Phone:630-584-1411
Practice Address - Fax:630-513-2630
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070012494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF2064OtherRAILROAD GROUP
IL070-012494OtherLICENSE #
IL753210OtherMEDICARE GROUP
ILK40726OtherMEDICARE