Provider Demographics
NPI:1861862534
Name:MERCY IN ACTION VINEYARD INC
Entity Type:Organization
Organization Name:MERCY IN ACTION VINEYARD INC
Other - Org Name:MERCY BIRTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PENWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPM, LM, BSM
Authorized Official - Phone:208-570-4578
Mailing Address - Street 1:3018 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3059
Mailing Address - Country:US
Mailing Address - Phone:208-608-5954
Mailing Address - Fax:208-575-8737
Practice Address - Street 1:3018 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3059
Practice Address - Country:US
Practice Address - Phone:208-608-5954
Practice Address - Fax:208-575-8737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY IN ACTION VINEYARD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-3261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMID-3OtherIDAHO BOARD OF OCCUPATIONAL LICENSING