1598144768 NPI number — RAINBOW CHILDREN'S CLINIC MAYFIELD, PA

Table of content: (NPI 1598144768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598144768 NPI number — RAINBOW CHILDREN'S CLINIC MAYFIELD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAINBOW CHILDREN'S CLINIC MAYFIELD, PA
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:
1598144768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1915 E MAYFIELD RD STE 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76014-2605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-276-6700
Provider Business Mailing Address Fax Number:
682-276-6049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 E MAYFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76014-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-276-6700
Provider Business Practice Location Address Fax Number:
682-276-6049
Provider Enumeration Date:
05/21/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BERNARDEZ-TAN
Authorized Official First Name:
RUTH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
682-276-6700

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  J8913 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 349462701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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