1972080810 NPI number — BOISE RIVER BIRTH CENTER AND WOMENS HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972080810 NPI number — BOISE RIVER BIRTH CENTER AND WOMENS HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOISE RIVER BIRTH CENTER AND WOMENS HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972080810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
806 EAGLE HILLS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-5212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-631-8910
Provider Business Mailing Address Fax Number:
208-639-2736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
182 W STATE ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-4959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-639-2700
Provider Business Practice Location Address Fax Number:
208-639-2736
Provider Enumeration Date:
07/24/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HAGADORN
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
LYN
Authorized Official Title or Position:
C0-OWNER
Authorized Official Telephone Number:
208-631-8910

Provider Taxonomy Codes

  • Taxonomy code: 261QB0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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