Healthcare Provider Details

I. General information

NPI: 1255474300
Provider Name (Legal Business Name): RAINBOW PEDIATRIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 E MAIN ST
HUMBOLDT TN
38343-2904
US

IV. Provider business mailing address

1636 E MAIN STREET
HUMBOLDT TN
38343
US

V. Phone/Fax

Practice location:
  • Phone: 731-784-7833
  • Fax: 731-660-8739
Mailing address:
  • Phone: 731-784-7833
  • Fax: 731-784-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41750
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: GINA M DIEUDONNE
Title or Position: OWNER
Credential: MD
Phone: 731-784-7833