Provider Demographics
NPI:1922093293
Name:LEWIS & CLARK ORTHOPAEDIC INSTITUTE LLC
Entity Type:Organization
Organization Name:LEWIS & CLARK ORTHOPAEDIC INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEENE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA CMPE
Authorized Official - Phone:208-298-1020
Mailing Address - Street 1:318 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-298-1050
Mailing Address - Fax:208-298-1060
Practice Address - Street 1:318 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-298-1050
Practice Address - Fax:208-298-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID611193000OtherOWCP
ID806919700Medicaid
ID04606OtherIBC
ID0198920OtherWLI
ID7124381OtherWWL
ID3570555OtherTRICARE
ID000010146573OtherRBS
ID04606OtherIBC
ID611193000OtherOWCP
ID1870555Medicare ID - Type Unspecified