Provider Demographics
NPI:1558154492
Name:RUSSET RIDGE HEALTHCARE LLC
Entity type:Organization
Organization Name:RUSSET RIDGE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:1140 N ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8716
Mailing Address - Country:US
Mailing Address - Phone:208-854-8500
Mailing Address - Fax:208-854-8665
Practice Address - Street 1:1140 N ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8716
Practice Address - Country:US
Practice Address - Phone:208-854-8500
Practice Address - Fax:208-854-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility