=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609892850
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND J BROADBENT CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15862 STATE HIGHWAY 110 N
-----------------------------------------------------
City | LINDALE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75771-5932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-939-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 IDAHO STREET
-----------------------------------------------------
City | VAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-963-1685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 529805
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------