Healthcare Provider Details

I. General information

NPI: 1992198469
Provider Name (Legal Business Name): CLARENCE YEAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 WHITE ST
MCCOMB MS
39648-2711
US

IV. Provider business mailing address

1701 WHITE ST
MCCOMB MS
39648-2711
US

V. Phone/Fax

Practice location:
  • Phone: 601-249-4217
  • Fax: 601-249-4234
Mailing address:
  • Phone: 601-249-4217
  • Fax: 601-249-4234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: