Basic Information
| Provider Information | |||||||||
| NPI: | 1326681214 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORELIFE VALLEY, LLC | ||||||||
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| OtherOrganizationName: | CORELIFE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009053261 | ||||||||
| FaxNumber: | 8557724748 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 CHICHESTER AVE UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | UPPER CHICHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190613149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4847686762 | ||||||||
| FaxNumber: | 8557724748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2019 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | KOSTKOWSKI | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4109910044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
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.