MEDICARE: BABY BOOMERS ACTIVITIES CLUB II, LLC

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	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1942635776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BABY BOOMERS ACTIVITIES CLUB II, LLC

Provider Business Mailing Address
First Line	:	850 S JONES BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-3730
Country	:	US
Telephone Number	:	702-878-9600
Fax Number	:	702-878-9605

Provider Business Practice Location Address
First Line	:	1915 SIMMONS ST STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-1666
Country	:	US
Telephone Number	:	702-878-9600
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	KATIUSHKA LOZANO DE POSADA
Credential	:
Telephone Number	:	702-878-9600

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	11/08/2018

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