1033455746 NPI number — RAINBOW EURALYPTUS INTERNAL MEDICINE LLC

Table of content: (NPI 1033455746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033455746 NPI number — RAINBOW EURALYPTUS INTERNAL MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAINBOW EURALYPTUS INTERNAL MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033455746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 WILLOW CREEK RD
Provider Second Line Business Mailing Address:
SUITE A 103 BOX 245
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301-6689
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-453-3799
Provider Business Mailing Address Fax Number:
702-453-5741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1016 TACOMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-2263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LABRECQUE
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCTS. MGR
Authorized Official Telephone Number:
702-453-3799

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  OP60309571 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OP60309571 . This is a "WA LIC" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".