Provider Demographics
NPI:1316659899
Name:LEWIS CLARK IMAGING, LLC
Entity type:Organization
Organization Name:LEWIS CLARK IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:
Authorized Official - Last Name:GWOST
Authorized Official - Suffix:
Authorized Official - Credentials:RVT, RDMS, RDCS
Authorized Official - Phone:360-391-9311
Mailing Address - Street 1:336 WARNER DR STE B
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:360-391-9311
Mailing Address - Fax:208-473-7304
Practice Address - Street 1:336 WARNER DR STE B
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:360-391-9311
Practice Address - Fax:208-473-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center