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General NPI Number Information
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NPI Number | 1073972972
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Entity Type | Organization
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Legal Business Name | BOYS & GIRLS CLUB OF EVANSTON
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Dates
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Enumeration Date | 02/19/2016
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Last Update Date | 02/19/2016
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Provider Practice Location Address
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Address Line | 419 4TH ST
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City | EVANSTON
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State | WY
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Zip | 82930-3616
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Country | US
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Telephone | 307-444-2582
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Fax |
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Provider Business Mailing Address
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Address Line | 419 4TH ST
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City | EVANSTON
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State | WY
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Zip | 82930-3616
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Country | US
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Telephone | 307-444-2582
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | HOLLY SLADE
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Credential |
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Telephone | 307-444-2582
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | WY
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