MEDICARE: KOOL LIVING, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1548706112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOOL LIVING, INC.

Provider Business Mailing Address
First Line	:	20138 ELKWOOD ST
Second Line	:
City	:	WINNETKA
State	:	CA
Zip	:	91306-2312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26362 VIA CANON
Second Line	:
City	:	CAPO BEACH
State	:	CA
Zip	:	92624-1214
Country	:	US
Telephone Number	:	323-870-7777
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NICHOLAS RUSSI
Credential	:
Telephone Number	:	951-427-4807

Provider Enumeration Date	:	01/06/2017
Last Update Date	:	11/06/2017

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Directions to “KOOL LIVING, INC. ” Practice Location

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