=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720535909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILADELPHIA FREEDOM VALLEY YOUNG MEN'S CHRISTIAN ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2016
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 891 N EAGLE RD
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-649-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 FAYETTE ST SUITE 250
-----------------------------------------------------
City | CONSHOHOCKEN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19428-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-592-4383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | SHAUN ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-963-3704
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------