Provider Demographics
NPI:1659838027
Name:RNBA LLC
Entity Type:Organization
Organization Name:RNBA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAND
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:719-251-5122
Mailing Address - Street 1:1943 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9657
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2688
Practice Address - Country:US
Practice Address - Phone:208-525-2090
Practice Address - Fax:208-523-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386616332OtherINDIVIDUAL NPI