Provider Demographics
NPI:1073003745
Name:CORELIFE INC
Entity Type:Organization
Organization Name:CORELIFE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-991-0044
Mailing Address - Street 1:1111 BENFIELD BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-3005
Mailing Address - Country:US
Mailing Address - Phone:443-679-4309
Mailing Address - Fax:855-772-4748
Practice Address - Street 1:3829 LORNA RD STE 312
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-7058
Practice Address - Country:US
Practice Address - Phone:205-710-2368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty