=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710522073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNG MEN'S AND WOMEN'S CHRISTIAN ASSOCIATION OF THE GREATER TR-VALLEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2019
-----------------------------------------------------
Last Update Date | 11/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 W BLOOMFIELD ST
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-4198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-336-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 W BLOOMFIELD ST
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-4198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-336-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEALTHY LIVING DIRECTOR
-----------------------------------------------------
Name | LEIGHNA M SCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-336-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------