Provider Demographics
NPI:1104219252
Name:YBANEZ, JOHNNY II (LMP)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:YBANEZ
Suffix:II
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E NEIDER AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6007
Mailing Address - Country:US
Mailing Address - Phone:208-930-4944
Mailing Address - Fax:888-443-4939
Practice Address - Street 1:320 E NEIDER AVE STE 105
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-6007
Practice Address - Country:US
Practice Address - Phone:208-930-4944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3734225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist