Provider Demographics
NPI:1003247925
Name:COOL WATERS, LLC
Entity Type:Organization
Organization Name:COOL WATERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERAATIONS AND FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MBAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-245-8327
Mailing Address - Street 1:4601 LOCUST LN STE 305
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4446
Mailing Address - Country:US
Mailing Address - Phone:717-545-2920
Mailing Address - Fax:
Practice Address - Street 1:4601 LOCUST LN STE 305
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4446
Practice Address - Country:US
Practice Address - Phone:717-545-2920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA06310501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102887053Medicaid