Provider Demographics
NPI:1275793796
Name:MOMS ARE US AND KIDS 2
Entity Type:Organization
Organization Name:MOMS ARE US AND KIDS 2
Other - Org Name:WILD ROSE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMERLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-551-9981
Mailing Address - Street 1:PO BOX 6762
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-0640
Mailing Address - Country:US
Mailing Address - Phone:509-586-6248
Mailing Address - Fax:509-586-7928
Practice Address - Street 1:207 N DENNIS ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3129
Practice Address - Country:US
Practice Address - Phone:509-586-6248
Practice Address - Fax:509-586-7928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9635319Medicaid
WA7900970Medicaid