Provider Demographics
NPI:1073062949
Name:KETTLE MORAINE YMCA, INC. YOUNG MEN'S CHRISTIAN ASSOCIATION
Entity Type:Organization
Organization Name:KETTLE MORAINE YMCA, INC. YOUNG MEN'S CHRISTIAN ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-247-1006
Mailing Address - Street 1:1111 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2433
Mailing Address - Country:US
Mailing Address - Phone:262-334-3405
Mailing Address - Fax:262-334-5414
Practice Address - Street 1:1111 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2433
Practice Address - Country:US
Practice Address - Phone:262-334-3405
Practice Address - Fax:262-334-5414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty