Provider Demographics
NPI:1023507290
Name:RAINVILLE, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RAINVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 CENTER DR STE D250
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-1258
Mailing Address - Country:US
Mailing Address - Phone:385-246-5971
Mailing Address - Fax:
Practice Address - Street 1:1154 CENTER DR STE D250
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-1258
Practice Address - Country:US
Practice Address - Phone:385-246-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13018873-1206363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant