MEDICARE: PRETTYBOY EMPIRE HOMES FOR LGBTQ YOUTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	NV20131464024	NV
2	251V00000X	Voluntary or Charitable Agency	NV20131464024	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NV20131464024	OTHER	NV	NV SOS

General Provider Information

NPI Number	:	1598188211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRETTYBOY EMPIRE HOMES FOR LGBTQ YOUTH

Provider Business Mailing Address
First Line	:	1205 S 10TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1506
Country	:	US
Telephone Number	:	917-981-0503
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 S 10TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1506
Country	:	US
Telephone Number	:	917-981-0503
Fax Number	:

Authorized Official
Title or Position	:	REVEREND
Name	:	MR. RAYMOND ARTHUR BESSE
Credential	:	M.DIV
Telephone Number	:	917-981-0503

Provider Enumeration Date	:	01/31/2014
Last Update Date	:	01/31/2014

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