MEDICARE: JOHN E ALEXANDER SOUTH WOOD COUNTY YOUNG MEN'S CHRISTIAN ASSOCIATION

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	:	1669923249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN E ALEXANDER SOUTH WOOD COUNTY YOUNG MEN'S CHRISTIAN ASSOCIATION

Provider Business Mailing Address
First Line	:	211 WISCONSIN RIVER DR
Second Line	:
City	:	PORT EDWARDS
State	:	WI
Zip	:	54469-1437
Country	:	US
Telephone Number	:	715-887-3240
Fax Number	:	715-887-3262

Provider Business Practice Location Address
First Line	:	211 WISCONSIN RIVER DR
Second Line	:
City	:	PORT EDWARDS
State	:	WI
Zip	:	54469-1437
Country	:	US
Telephone Number	:	715-887-3240
Fax Number	:	715-887-3262

Authorized Official
Title or Position	:	FINANCE DIRECTOR
Name	:	CHRISTINA CONRAD
Credential	:
Telephone Number	:	715-818-6016

Provider Enumeration Date	:	10/19/2016
Last Update Date	:	03/31/2017

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