Provider Demographics
NPI:1720670573
Name:BOYS TOWN NEVADA, INC.
Entity Type:Organization
Organization Name:BOYS TOWN NEVADA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ETZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-724-8402
Mailing Address - Street 1:6460 MEDICAL CENTER ST STE 140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2420
Mailing Address - Country:US
Mailing Address - Phone:702-888-1340
Mailing Address - Fax:
Practice Address - Street 1:8390 W WINDMILL LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-4420
Practice Address - Country:US
Practice Address - Phone:702-329-3208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty