Provider Demographics
NPI:1912193798
Name:RAINBOW CITY FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:RAINBOW CITY FAMILY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:V
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-442-9350
Mailing Address - Street 1:115 W GRAND AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:RAINBOW CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35906-3275
Mailing Address - Country:US
Mailing Address - Phone:256-442-9350
Mailing Address - Fax:256-442-9352
Practice Address - Street 1:115 W GRAND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-3275
Practice Address - Country:US
Practice Address - Phone:256-442-9350
Practice Address - Fax:256-442-9352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-732-TA-108332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009946420Medicaid
AL102G705904Medicare PIN