Provider Demographics
NPI:1598890188
Name:BOULDER FOOT & ANKLE CENTER, LTD.
Entity Type:Organization
Organization Name:BOULDER FOOT & ANKLE CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-293-5036
Mailing Address - Street 1:PO BOX 1344
Mailing Address - Street 2:
Mailing Address - City:OVERTON
Mailing Address - State:NV
Mailing Address - Zip Code:89040-1344
Mailing Address - Country:US
Mailing Address - Phone:702-293-5036
Mailing Address - Fax:866-409-1683
Practice Address - Street 1:999 ADAMS BLVD
Practice Address - Street 2:STE 103
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2244
Practice Address - Country:US
Practice Address - Phone:702-293-5036
Practice Address - Fax:866-409-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV9807213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002102008Medicaid
NV480031437OtherRAILROAD MEDICARE
NV002102008Medicaid
NVV34345Medicare PIN
NV3976150001Medicare NSC