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General NPI Number Information
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NPI Number | 1518126119
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Entity Type | Organization
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Legal Business Name | RIVER OF NO RETURN ANESTHESIA
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 06/09/2008
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Provider Practice Location Address
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Address Line | 203 S DAISY ST
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City | SALMON
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State | ID
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Zip | 83467
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Country | US
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Telephone | 208-756-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 42 WILD ROSE RD
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City | SALMON
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State | ID
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Zip | 83467-5277
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Country | US
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Telephone | 208-756-2429
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CECIL T. JACKSON
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Credential | C.R.N.A.
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Telephone | 208-756-2429
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RNA-411
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License Number State | ID
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