Provider Demographics
NPI:1184825408
Name:APN RAINBOW PEDIATRIC SERVICES, PLLC
Entity Type:Organization
Organization Name:APN RAINBOW PEDIATRIC SERVICES, PLLC
Other - Org Name:RAINBOW PEDIATRIC SERVICES, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILOU
Authorized Official - Middle Name:
Authorized Official - Last Name:SHREVE-DOFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:479-464-8231
Mailing Address - Street 1:5507 WALSH LANE
Mailing Address - Street 2:STE 101
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8941
Mailing Address - Country:US
Mailing Address - Phone:479-464-8231
Mailing Address - Fax:479-464-8230
Practice Address - Street 1:5507 WALSH LANE
Practice Address - Street 2:STE 101
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8941
Practice Address - Country:US
Practice Address - Phone:479-464-8231
Practice Address - Fax:479-464-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR208000000X
ARA01589363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155833762Medicaid
AR5F294OtherAR BCBS