=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265152276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BATTLE BORN BEHAVIOR CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2022
-----------------------------------------------------
Last Update Date | 08/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9260 W SUNSET RD STE 204
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-241-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9898 SCOTTISH GLEN CT
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89178-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-241-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MR. THOMAS WILLIAN BOWEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-241-5568
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------