Healthcare Provider Details

I. General information

NPI: 1972080810
Provider Name (Legal Business Name): BOISE RIVER BIRTH CENTER AND WOMENS HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 W STATE ST STE B
EAGLE ID
83616-4959
US

IV. Provider business mailing address

806 EAGLE HILLS WAY
EAGLE ID
83616-5212
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-2700
  • Fax: 208-639-2736
Mailing address:
  • Phone: 208-631-8910
  • Fax: 208-639-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRACY LYN HAGADORN
Title or Position: C0-OWNER
Credential: LM, CPM
Phone: 208-631-8910