Healthcare Provider Details

I. General information

NPI: 1255332383
Provider Name (Legal Business Name): KIMBERLY HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 BIRCH ST
DOUGLAS WY
82633-2761
US

IV. Provider business mailing address

1108 BIRCH ST
DOUGLAS WY
82633-2761
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-3397
  • Fax:
Mailing address:
  • Phone: 307-358-3397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number06-116
License Number StateWY

VIII. Authorized Official

Name: MRS. BEVERLY J WILSON
Title or Position: ADMINISTRATOR/OWNER
Credential: RN
Phone: 307-358-3397