Provider Demographics
NPI:1508207176
Name:LUST RUEB, KIMBERLY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LYNN
Last Name:LUST RUEB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:LUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:1621 MARKET PLACE DR
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-3480
Practice Address - Country:US
Practice Address - Phone:406-454-2202
Practice Address - Fax:406-452-1020
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60373324152W00000X
IDODP-100315152W00000X
MTOPT-OPT-LIC-2223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508207176Medicaid
WA2038492Medicaid
MT1508207176Medicaid
OR1508207176Medicaid