Basic Information
| Provider Information | |||||||||
| NPI: | 1033455746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAINBOW EURALYPTUS INTERNAL MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3196 WILLOW CREEK RD | ||||||||
| Address2: | SUITE A 103 BOX 245 | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1016 TACOMA AVE | ||||||||
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| City: | SUNNYSIDE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989442263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098371500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2012 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCTS. MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | OP60309571 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | OP60309571 | 01 | WA | WA LIC | OTHER |