Provider Demographics
NPI:1649366477
Name:LEWIS CLARK STATE COLLEGE
Entity type:Organization
Organization Name:LEWIS CLARK STATE COLLEGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-792-2216
Mailing Address - Street 1:500 8TH AVE
Mailing Address - Street 2:ADM 207
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2691
Mailing Address - Country:US
Mailing Address - Phone:208-792-2216
Mailing Address - Fax:208-792-2822
Practice Address - Street 1:500 8TH AVE
Practice Address - Street 2:SGC #42
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2691
Practice Address - Country:US
Practice Address - Phone:208-792-2251
Practice Address - Fax:208-792-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6537261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF94678Medicare UPIN