- Facility Name
- PROVIDENT FOUNDATION - WEDGEWOOD TERRACE LLC
- Type / Classification
- Assisted Living Facility
- Address
- 2114 VINEYARD AVENUE, LEWISTON, ID 83501
- Phone Number
- (208) 743-4545
- NPI Number
- 1295228054
- Authorized Official
- DEBRA LOCKWOOD (President & Chief Financial Officer)
- Enumeration Date
- 2018-06-07