Healthcare Provider Details

I. General information

NPI: 1215153770
Provider Name (Legal Business Name): GWENDOLYN WILKES RAINBOW CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 BUENA VISTA RD
COLUMBUS GA
31906-3121
US

IV. Provider business mailing address

2201 BUENA VISTA RD
COLUMBUS GA
31906-3121
US

V. Phone/Fax

Practice location:
  • Phone: 706-320-9012
  • Fax: 706-320-9021
Mailing address:
  • Phone: 706-320-9012
  • Fax: 706-320-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. GLORIA A RODGERS
Title or Position: COORDINATOR
Credential: DO
Phone: 706-320-9012