Basic Information
| Provider Information | |||||||||
| NPI: | 1043892672 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORELIFE ALABAMA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436886909 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3829 LORNA RD | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352447034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057102368 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEEHAN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, RCM | ||||||||
| AuthorizedOfficialTelephone: | 4434396309 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.