Provider Demographics
NPI:1912575424
Name:RJN BOISE, LLC
Entity Type:Organization
Organization Name:RJN BOISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:NILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-409-8798
Mailing Address - Street 1:2000 S PEPPERCORN PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2249
Mailing Address - Country:US
Mailing Address - Phone:208-409-8798
Mailing Address - Fax:
Practice Address - Street 1:2000 S PEPPERCORN PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2249
Practice Address - Country:US
Practice Address - Phone:208-409-8798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID4295493Medicaid