Organization
YOUR VILLAGE STL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER TIETJEN CPNP (OWNER)
(314) 753-3982
Entity
Organization
Contact information
Practice address
1719 BIG HORN BASIN DR, WILDWOOD, MO 63011-4821
(314) 753-3982
Mailing address
1719 BIG HORN BASIN DR, WILDWOOD, MO 63011-4821
(314) 753-3982
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
Other
Enumeration date
10/18/2022
Last updated
10/18/2022
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