Healthcare Provider Details

I. General information

NPI: 1881196012
Provider Name (Legal Business Name): BAMBOO FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 03/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 E LAKE MEAD PKWY STE 307
HENDERSON NV
89015-6444
US

IV. Provider business mailing address

PO BOX 13603
LAS VEGAS NV
89112-1603
US

V. Phone/Fax

Practice location:
  • Phone: 702-433-3038
  • Fax: 702-949-1975
Mailing address:
  • Phone: 702-433-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY HOLDEMAN
Title or Position: OWNER
Credential:
Phone: 702-433-3038