Basic Information
| Provider Information | |||||||||
| NPI: | 1659838027 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RNBA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1943 CRESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838439657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 HILAND AVE | ||||||||
| Address2: | |||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2019 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | BRACKEN | ||||||||
| AuthorizedOfficialFirstName: | RAND | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7192515122 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1386616332 | 01 | ID | INDIVIDUAL NPI | OTHER |