Provider Demographics
NPI:1689127961
Name:COOLWATERS FOUNDATION
Entity Type:Organization
Organization Name:COOLWATERS FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTER
Authorized Official - Middle Name:N
Authorized Official - Last Name:MBAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-245-8327
Mailing Address - Street 1:4601 LOCUST LN
Mailing Address - Street 2:STE:305
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4444
Mailing Address - Country:US
Mailing Address - Phone:717-657-3976
Mailing Address - Fax:
Practice Address - Street 1:4601 LOCUST LN
Practice Address - Street 2:STE:305
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4444
Practice Address - Country:US
Practice Address - Phone:717-657-3976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA7000000313332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7000000313Medicaid