Provider Demographics
NPI:1477063386
Name:CORELIFE OF DELMARVA LLC
Entity Type:Organization
Organization Name:CORELIFE OF DELMARVA LLC
Other - Org Name:CORELIFE
Other - Org Type:Doing Business As
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:443-679-4309
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 1:200 E VINE ST STE B
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5531
Practice Address - Country:US
Practice Address - Phone:443-358-6239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty