Provider Demographics
NPI:1437250743
Name:KIMBERLY MATHAI MS RD
Entity Type:Organization
Organization Name:KIMBERLY MATHAI MS RD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHAI
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD
Authorized Official - Phone:206-363-5420
Mailing Address - Street 1:PO BOX 1718
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98071-1718
Mailing Address - Country:US
Mailing Address - Phone:253-833-3255
Mailing Address - Fax:253-288-2203
Practice Address - Street 1:2111 N NORTHGATE WAY STE 217
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9018
Practice Address - Country:US
Practice Address - Phone:206-363-5420
Practice Address - Fax:206-283-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000974133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7600844Medicaid
WAGAB27088Medicare ID - Type UnspecifiedMEDICARE