Provider Demographics
NPI:1578012936
Name:STATELINE FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC
Entity Type:Organization
Organization Name:STATELINE FAMILY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-365-2261
Mailing Address - Street 1:1865 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3521
Mailing Address - Country:US
Mailing Address - Phone:608-365-2261
Mailing Address - Fax:608-365-7091
Practice Address - Street 1:1865 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3521
Practice Address - Country:US
Practice Address - Phone:608-365-2261
Practice Address - Fax:608-365-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty