Provider Demographics
NPI:1881196012
Name:BAMBOO FAMILY CLINIC LLC
Entity type:Organization
Organization Name:BAMBOO FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:PO BOX 13603
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89112-1603
Mailing Address - Country:US
Mailing Address - Phone:702-433-3038
Mailing Address - Fax:
Practice Address - Street 1:98 E LAKE MEAD PKWY STE 307
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-6444
Practice Address - Country:US
Practice Address - Phone:702-433-3038
Practice Address - Fax:702-949-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care