Provider Demographics
NPI:1770247769
Name:CORLIFE, LLC
Entity type:Organization
Organization Name:CORLIFE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR OF LICENSURE AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:WALT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-882-3715
Mailing Address - Street 1:805 BROOK ST STE 402
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3431
Mailing Address - Country:US
Mailing Address - Phone:314-882-3715
Mailing Address - Fax:
Practice Address - Street 1:330 N BROADWAY
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2510
Practice Address - Country:US
Practice Address - Phone:888-770-7194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies