Healthcare Provider Details

I. General information

NPI: 1912393612
Provider Name (Legal Business Name): LIVING EVOLUTION: AN OUTDOOR EXPERIENTIAL LEARNING PROGRAM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 BUTTLER LANE SUITE 206
SCOTTS VALLEY CA
95066
US

IV. Provider business mailing address

4678 SOQUEL DRIVE #362
SOQUEL CA
95073
US

V. Phone/Fax

Practice location:
  • Phone: 831-247-3984
  • Fax:
Mailing address:
  • Phone: 831-247-3984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: JORDEN R. KRIMMER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MACP
Phone: 831-247-3984