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General NPI Number Information
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NPI Number | 1578012936
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Entity Type | Organization
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Legal Business Name | STATELINE FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC
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Dates
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Enumeration Date | 09/27/2016
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Last Update Date | 09/27/2016
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Provider Practice Location Address
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Address Line | 1865 RIVERSIDE DR
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City | BELOIT
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State | WI
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Zip | 53511-3521
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Country | US
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Telephone | 608-365-2261
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Fax | 608-365-7091
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Provider Business Mailing Address
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Address Line | 1865 RIVERSIDE DR
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City | BELOIT
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State | WI
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Zip | 53511-3521
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Country | US
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Telephone | 608-365-2261
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Fax | 608-365-7091
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Authorized Official
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Title or Position | CEO/EXECUTIVE DIRECTOR
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Name | MR. DOUG BRITT
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Credential |
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Telephone | 608-365-2261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number |
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License Number State |
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