Provider Demographics
NPI:1205552643
Name:YOUR VILLAGE STL LLC
Entity type:Organization
Organization Name:YOUR VILLAGE STL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TIETJEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:314-753-3982
Mailing Address - Street 1:1719 BIG HORN BASIN DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4821
Mailing Address - Country:US
Mailing Address - Phone:314-753-3982
Mailing Address - Fax:
Practice Address - Street 1:1719 BIG HORN BASIN DR
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63011-4821
Practice Address - Country:US
Practice Address - Phone:314-753-3982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty