Provider Demographics
NPI:1871044883
Name:KOOL RIDEZ LLC
Entity Type:Organization
Organization Name:KOOL RIDEZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-880-9981
Mailing Address - Street 1:1803 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4810
Mailing Address - Country:US
Mailing Address - Phone:208-880-9981
Mailing Address - Fax:
Practice Address - Street 1:1803 ELLIS AVE.
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-880-9981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1356792998251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1356792998Medicaid