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General NPI Number Information
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NPI Number | 1811542103
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Entity Type | Individual
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Provider Name | JORDAN VERBANAZ
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Gender | Male
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Dates
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Enumeration Date | 08/05/2019
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Last Update Date | 08/08/2024
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Provider Practice Location Address
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Address Line | 718 LUETKENHAUS BLVD
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City | WENTZVILLE
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State | MO
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Zip | 63385-3515
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Country | US
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Telephone | 636-445-5001
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Fax |
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Provider Business Mailing Address
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Address Line | 647 SPIRIT AIRPARK WEST DR STE 101
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City | CHESTERFIELD
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State | MO
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Zip | 63005-1032
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Country | US
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Telephone | 636-223-5700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2019030179
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License Number State |
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