MEDICARE: ITASCA COUNTY FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator

General Provider Information

NPI Number	:	1306393178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITASCA COUNTY FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.

Provider Business Mailing Address
First Line	:	400 RIVER RD
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3784
Country	:	US
Telephone Number	:	218-327-1161
Fax Number	:	218-327-8813

Provider Business Practice Location Address
First Line	:	400 RIVER RD
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3784
Country	:	US
Telephone Number	:	218-327-1161
Fax Number	:	218-327-8813

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ELIZABETH ANN MCBRIDE
Credential	:
Telephone Number	:	218-327-8808

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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