Provider Demographics
NPI:1942635776
Name:BABY BOOMERS ACTIVITIES CLUB II, LLC
Entity Type:Organization
Organization Name:BABY BOOMERS ACTIVITIES CLUB II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATIUSHKA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOZANO DE POSADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-878-9600
Mailing Address - Street 1:850 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-3730
Mailing Address - Country:US
Mailing Address - Phone:702-878-9600
Mailing Address - Fax:702-878-9605
Practice Address - Street 1:1915 SIMMONS ST STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1666
Practice Address - Country:US
Practice Address - Phone:702-878-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care