Provider Demographics
NPI:1477925618
Name:KOOL LIVING, INC.
Entity Type:Organization
Organization Name:KOOL LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-427-4807
Mailing Address - Street 1:20138 ELKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26421 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8564
Practice Address - Country:US
Practice Address - Phone:951-427-4807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300332DP251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health