Healthcare Provider Details

I. General information

NPI: 1437499266
Provider Name (Legal Business Name): RAELLE ANESTHESIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10694 MAGNOLIA AVE
RIVERSIDE CA
92505-1816
US

IV. Provider business mailing address

10694 MAGNOLIA AVE
RIVERSIDE CA
92505-1816
US

V. Phone/Fax

Practice location:
  • Phone: 951-335-5264
  • Fax: 951-335-5471
Mailing address:
  • Phone: 951-335-5264
  • Fax: 951-335-5471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4114
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3956
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3970
License Number StateCA

VIII. Authorized Official

Name: WAYLAN WYATT KRUSE
Title or Position: CEO
Credential: CRNA
Phone: 951-335-5461