Provider Demographics
NPI:1518126119
Name:RIVER OF NO RETURN ANESTHESIA
Entity Type:Organization
Organization Name:RIVER OF NO RETURN ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:T
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-756-2429
Mailing Address - Street 1:42 WILD ROSE RD
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5277
Mailing Address - Country:US
Mailing Address - Phone:208-756-2429
Mailing Address - Fax:
Practice Address - Street 1:203 S DAISY ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467
Practice Address - Country:US
Practice Address - Phone:208-756-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-411367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8M665OtherBLUE CROSS OF IDAHO
IDOTH000Medicaid
IDOTH000Medicaid