=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811406648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOOR COUNTY YOUNG MEN'S CHRISTIAN ASSOCIATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2017
-----------------------------------------------------
Last Update Date | 09/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 MICHIGAN STREET
-----------------------------------------------------
City | STURGEON BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-743-4949
-----------------------------------------------------
Fax | 920-743-8812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 MICHIGAN STREET
-----------------------------------------------------
City | STURGEON BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-743-4949
-----------------------------------------------------
Fax | 920-743-8812
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. THOMAS RICHARD BEERNTSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-743-4949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------