Provider Demographics
NPI:1548605835
Name:RAINBOW CHILDREN'S CLINIC 3, P.A.
Entity Type:Organization
Organization Name:RAINBOW CHILDREN'S CLINIC 3, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARDEZ-TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-642-3364
Mailing Address - Street 1:929 W PIONEER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-4726
Mailing Address - Country:US
Mailing Address - Phone:972-641-3364
Mailing Address - Fax:972-641-3369
Practice Address - Street 1:929 W PIONEER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4726
Practice Address - Country:US
Practice Address - Phone:972-641-3364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3163081-01Medicaid