=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962372359
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIAN HARBOR YOUTH CAMP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2025
-----------------------------------------------------
Last Update Date | 11/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10520 24TH AVE
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-5091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-497-4429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10520 24TH AVE
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-5091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-497-4429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARIA STONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-497-4429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 177F00000X
-----------------------------------------------------
Taxonomy Name | Lodging Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------