Healthcare Provider Details

I. General information

NPI: 1417319567
Provider Name (Legal Business Name): DR. CY CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 CHILDRENS PL FL PLACE6
SAINT LOUIS MO
63110-1020
US

IV. Provider business mailing address

908 SAN SABA DR
SOUTHLAKE TX
76092-6222
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-4127
  • Fax: 314-454-4298
Mailing address:
  • Phone: 817-946-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: