Healthcare Provider Details

I. General information

NPI: 1467268953
Provider Name (Legal Business Name): LC-ADVANCED HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 G ST
LEWISTON ID
83501-2031
US

IV. Provider business mailing address

1428 G ST
LEWISTON ID
83501-2031
US

V. Phone/Fax

Practice location:
  • Phone: 208-848-4140
  • Fax: 208-848-4143
Mailing address:
  • Phone: 208-848-4140
  • Fax: 208-848-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY BRIAN TENNY
Title or Position: OWNER
Credential: MSW, CADC
Phone: 208-816-0015