Provider Demographics
NPI:1255844403
Name:YEAGLEY, MAX WARREN
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:WARREN
Last Name:YEAGLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 S HAM LN STE B
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3532
Mailing Address - Country:US
Mailing Address - Phone:209-368-7433
Mailing Address - Fax:209-222-6182
Practice Address - Street 1:631 S HAM LN STE B
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3532
Practice Address - Country:US
Practice Address - Phone:209-368-7433
Practice Address - Fax:209-222-6182
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist