Provider Demographics
NPI:1912393612
Name:LIVING EVOLUTION: AN OUTDOOR EXPERIENTIAL LEARNING PROGRAM INC.
Entity Type:Organization
Organization Name:LIVING EVOLUTION: AN OUTDOOR EXPERIENTIAL LEARNING PROGRAM INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JORDEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KRIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:MACP
Authorized Official - Phone:831-247-3984
Mailing Address - Street 1:4678 SOQUEL DRIVE
Mailing Address - Street 2:#362
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073
Mailing Address - Country:US
Mailing Address - Phone:831-247-3984
Mailing Address - Fax:
Practice Address - Street 1:6001 BUTTLER LANE
Practice Address - Street 2:SUITE 206
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066
Practice Address - Country:US
Practice Address - Phone:831-247-3984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty