Healthcare Provider Details

I. General information

NPI: 1295214039
Provider Name (Legal Business Name): JOHN YANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10176 CORPORATE SQUARE DR STE 100S
SAINT LOUIS MO
63132-2924
US

IV. Provider business mailing address

16 TRAILRIDGE CT
SAINT CHARLES MO
63301-3231
US

V. Phone/Fax

Practice location:
  • Phone: 636-486-7174
  • Fax:
Mailing address:
  • Phone: 314-479-1836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: