Provider Demographics
NPI:1174930572
Name:AMAZING RAINBOW INC
Entity type:Organization
Organization Name:AMAZING RAINBOW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FUKUDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-528-6858
Mailing Address - Street 1:721 NEVADA ST
Mailing Address - Street 2:404
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8079
Mailing Address - Country:US
Mailing Address - Phone:909-528-6858
Mailing Address - Fax:909-798-9999
Practice Address - Street 1:721 NEVADA ST
Practice Address - Street 2:404
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8079
Practice Address - Country:US
Practice Address - Phone:909-528-6858
Practice Address - Fax:909-798-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH99603Medicare UPIN