Provider Demographics
NPI:1407021413
Name:RAINBOW CHILDREN'S CLINIC, P.A.
Entity Type:Organization
Organization Name:RAINBOW CHILDREN'S CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:BERNARDEZ
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-602-1166
Mailing Address - Street 1:2985 S STATE HIGHWAY 360
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7615
Mailing Address - Country:US
Mailing Address - Phone:972-602-1166
Mailing Address - Fax:972-602-1160
Practice Address - Street 1:2985 S STATE HIGHWAY 360
Practice Address - Street 2:SUITE 140
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7615
Practice Address - Country:US
Practice Address - Phone:972-602-1166
Practice Address - Fax:972-602-1160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197309102Medicaid
TX197309101Medicaid
TX045321904Medicaid
TXG19885OtherUPIN
TX045321903Medicaid