Healthcare Provider Details

I. General information

NPI: 1528973534
Provider Name (Legal Business Name): HAVASU RAINBOW PEDIATRICS AND ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 RIVIERA DR
LAKE HAVASU CITY AZ
86403-5735
US

IV. Provider business mailing address

150 RIVIERA DR
LAKE HAVASU CITY AZ
86403-5735
US

V. Phone/Fax

Practice location:
  • Phone: 928-540-5437
  • Fax: 928-540-5438
Mailing address:
  • Phone: 928-540-5437
  • Fax: 928-540-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY RENEE GOLDEN
Title or Position: MEMBER MANAGER
Credential: DNP
Phone: 317-414-5202