Provider Demographics
NPI:1326449646
Name:TRACI A. KIMBALL MD PC
Entity Type:Organization
Organization Name:TRACI A. KIMBALL MD PC
Other - Org Name:THE WISH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-557-6510
Mailing Address - Street 1:10050 RALSTON RD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004-4974
Mailing Address - Country:US
Mailing Address - Phone:720-577-4584
Mailing Address - Fax:720-577-4587
Practice Address - Street 1:10050 RALSTON RD UNIT 3
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-4974
Practice Address - Country:US
Practice Address - Phone:720-577-4584
Practice Address - Fax:720-577-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41180259Medicaid
CO418236Medicare UPIN