Provider Demographics
NPI:1174163760
Name:YOUNGER, DWAYNE LAMONT
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:LAMONT
Last Name:YOUNGER
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 1:1150 BLUE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:VERNON HILL
Mailing Address - State:VA
Mailing Address - Zip Code:24597-3091
Mailing Address - Country:US
Mailing Address - Phone:434-222-8894
Mailing Address - Fax:434-476-1539
Practice Address - Street 1:1150 BLUE ROCK RD
Practice Address - Street 2:
Practice Address - City:VERNON HILL
Practice Address - State:VA
Practice Address - Zip Code:24597-3091
Practice Address - Country:US
Practice Address - Phone:434-222-8894
Practice Address - Fax:434-476-1539
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT62202755347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle