Provider Demographics
NPI:1962035212
Name:KORAL, LEVI ADAM (DSOM, LOM)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:ADAM
Last Name:KORAL
Suffix:
Gender:M
Credentials:DSOM, LOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4720
Mailing Address - Country:US
Mailing Address - Phone:570-262-1133
Mailing Address - Fax:
Practice Address - Street 1:900 RUTTER AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4962
Practice Address - Country:US
Practice Address - Phone:570-262-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000275171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty