Provider Demographics
NPI:1972080810
Name:BOISE RIVER BIRTH CENTER AND WOMENS HEALTH
Entity Type:Organization
Organization Name:BOISE RIVER BIRTH CENTER AND WOMENS HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C0-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:HAGADORN
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:208-631-8910
Mailing Address - Street 1:806 EAGLE HILLS WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5212
Mailing Address - Country:US
Mailing Address - Phone:208-631-8910
Mailing Address - Fax:208-639-2736
Practice Address - Street 1:182 W STATE ST STE B
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4959
Practice Address - Country:US
Practice Address - Phone:208-639-2700
Practice Address - Fax:208-639-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing