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	7787ACD-0	NV

General Provider Information

NPI Number	:	1992159594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BABY BOOMERS ACTIVITIES CLUB II, LLC

Provider Business Mailing Address
First Line	:	1915 SIMMONS ST
Second Line	:	BLD 26
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-1666
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1915 SIMMONS ST
Second Line	:	BLD 26
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	:	04/20/2016
Last Update Date	:	11/08/2018

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