Provider Demographics
NPI:1588371439
Name:BAMBOO GARDEN ONE LLC
Entity type:Organization
Organization Name:BAMBOO GARDEN ONE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-689-6658
Mailing Address - Street 1:620 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4740
Mailing Address - Country:US
Mailing Address - Phone:503-689-6658
Mailing Address - Fax:971-423-0378
Practice Address - Street 1:651 HIGH ST NE STE 110
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2490
Practice Address - Country:US
Practice Address - Phone:503-689-6658
Practice Address - Fax:971-423-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty