MEDICARE: BAMBOO FAMILY CLINIC LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QP2300X	Primary Care Clinic/Center
3	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1881196012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAMBOO FAMILY CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 13603
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89112-1603
Country	:	US
Telephone Number	:	702-433-3038
Fax Number	:

Provider Business Practice Location Address
First Line	:	98 E LAKE MEAD PKWY STE 307
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-6444
Country	:	US
Telephone Number	:	702-433-3038
Fax Number	:	702-949-1975

Authorized Official
Title or Position	:	OWNER
Name	:	SHIRLEY HOLDEMAN
Credential	:
Telephone Number	:	702-433-3038

Provider Enumeration Date	:	03/03/2018
Last Update Date	:	03/03/2018

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