Provider Demographics
NPI:1801925516
Name:YOUNG, CHARLES-WARREN VICTOR (MLA, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:CHARLES-WARREN
Middle Name:VICTOR
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MLA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:ATHLETIC TRAINING ROOM
Mailing Address - Street 2:5800 OWNBY DR.
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75275-0001
Mailing Address - Country:US
Mailing Address - Phone:214-768-1704
Mailing Address - Fax:214-768-1225
Practice Address - Street 1:ATHLETIC TRAINING ROOM
Practice Address - Street 2:5800 OWNBY DR.
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75275-0001
Practice Address - Country:US
Practice Address - Phone:214-768-1704
Practice Address - Fax:214-768-1225
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT26682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT2668OtherSTATE ATHLETIC TRAINER LI