=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639626674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OSHKOSH COMMUNITY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2016
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3303 W 20TH AVE
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54904-9249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-230-8439
-----------------------------------------------------
Fax | 920-230-8444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3303 W 20TH AVE
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54904-9249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-230-8439
-----------------------------------------------------
Fax | 920-230-8444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HIPPA COMPLIANCE OFFICER
-----------------------------------------------------
Name | MR. DAN BRAUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-230-8915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------