Healthcare Provider Details

I. General information

NPI: 1942577994
Provider Name (Legal Business Name): BAMBOO SUNRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 E LAKE MEAD PKWY STE 201
HENDERSON NV
89015-6443
US

IV. Provider business mailing address

98 E LAKE MEAD PKWY STE 201
HENDERSON NV
89015-6443
US

V. Phone/Fax

Practice location:
  • Phone: 702-433-3038
  • Fax:
Mailing address:
  • Phone: 702-433-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY LIM HOLDEMAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 702-433-3038