MEDICARE: RUSSET RIDGE HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1558154492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSET RIDGE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	1140 N ALLUMBAUGH ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8716
Country	:	US
Telephone Number	:	208-501-7200
Fax Number	:	208-337-4892

Provider Business Practice Location Address
First Line	:	1140 N ALLUMBAUGH ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8716
Country	:	US
Telephone Number	:	208-501-7200
Fax Number	:	208-337-4892

Authorized Official
Title or Position	:	SECRETARY
Name	:	SOON BURNAM
Credential	:
Telephone Number	:	949-540-1249

Provider Enumeration Date	:	05/23/2025
Last Update Date	:	04/15/2026

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