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General NPI Number Information
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NPI Number | 1609311679
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE VA FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION
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Dates
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Enumeration Date | 12/30/2016
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Last Update Date | 12/30/2016
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Provider Practice Location Address
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Address Line | 580 COMMERCE RD
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City | FARMVILLE
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State | VA
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Zip | 23901-2999
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Country | US
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Telephone | 434-392-3456
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Fax |
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Provider Business Mailing Address
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Address Line | 580 COMMERCE RD
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City | FARMVILLE
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State | VA
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Zip | 23901-2999
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Country | US
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Telephone | 434-392-3456
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | BEN SYSKO
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Credential |
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Telephone | 434-392-3456
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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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