Healthcare Provider Details

I. General information

NPI: 1881200517
Provider Name (Legal Business Name): VANNVEI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 17TH ST
LEWISTON ID
83501-3652
US

IV. Provider business mailing address

PO BOX 341
LEWISTON ID
83501-0341
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-8416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TERESA GALL
Title or Position: CONTROLLER
Credential:
Phone: 509-758-5511