MEDICARE: BAMBOO SUNRISE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TP2701X	Group Psychotherapy Psychologist
2	103TR0400X	Rehabilitation Psychologist
3	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse
4	163WP0808X	Psychiatric/Mental Health Registered Nurse
5	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse
6	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942577994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAMBOO SUNRISE LLC

Provider Business Mailing Address
First Line	:	98 E LAKE MEAD PKWY STE 201
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-6443
Country	:	US
Telephone Number	:	702-433-3038
Fax Number	:

Provider Business Practice Location Address
First Line	:	98 E LAKE MEAD PKWY STE 201
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-6443
Country	:	US
Telephone Number	:	702-433-3038
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	SHIRLEY LIM HOLDEMAN
Credential	:
Telephone Number	:	702-433-3038

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	09/10/2021

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