Basic Information
Provider Information | |||||||||
NPI: | 1952845935 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAINBOW CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 BRIGHTON ST | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | MI | ||||||||
PostalCode: | 482032537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3134016858 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12501 HAMILTON AVE | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | MI | ||||||||
PostalCode: | 482033243 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138651580 | ||||||||
FaxNumber: | 3138651582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2016 | ||||||||
LastUpdateDate: | 12/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCOTT | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
AuthorizedOfficialTelephone: | 3134016858 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X |   |   | Y |   | Managed Care Organizations | Point of Service |   |
No ID Information.