=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740739275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OWEN COUNTY FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2016
-----------------------------------------------------
Last Update Date | 04/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 W. STATE HWY 46
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-828-9622
-----------------------------------------------------
Fax | 812-828-9329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 W. STATE HWY 46
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-828-9622
-----------------------------------------------------
Fax | 812-828-9329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | CONNIE J. KAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-828-9622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------