Provider Demographics
NPI:1760171938
Name:BAMBOO SUNRISE LLC
Entity Type:Organization
Organization Name:BAMBOO SUNRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-433-3038
Mailing Address - Street 1:98 E LAKE MEAD PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-6443
Mailing Address - Country:US
Mailing Address - Phone:702-433-3038
Mailing Address - Fax:
Practice Address - Street 1:6171 W CHARLESTON BLVD BLDG 11
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-433-3038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility