Healthcare Provider Details

I. General information

NPI: 1649366477
Provider Name (Legal Business Name): LEWIS CLARK STATE COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 8TH AVE SGC #42
LEWISTON ID
83501-2691
US

IV. Provider business mailing address

500 8TH AVE ADM 207
LEWISTON ID
83501-2691
US

V. Phone/Fax

Practice location:
  • Phone: 208-792-2251
  • Fax: 208-792-2882
Mailing address:
  • Phone: 208-792-2216
  • Fax: 208-792-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberM6537
License Number StateID

VIII. Authorized Official

Name: DR. DENE KAY THOMAS
Title or Position: PRESIDENT
Credential: PHD
Phone: 208-792-2216