Provider Demographics
NPI:1760778070
Name:YOUTH HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:YOUTH HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:KEESLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-922-2700
Mailing Address - Street 1:880 PARSONS RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3622
Mailing Address - Country:US
Mailing Address - Phone:231-922-6416
Mailing Address - Fax:231-922-6472
Practice Address - Street 1:880 PARSONS RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3622
Practice Address - Country:US
Practice Address - Phone:231-922-6416
Practice Address - Fax:231-922-6472
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND TRAVERSE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028725261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center