=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326681214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORELIFE VALLEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2019
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 CHICHESTER AVE UNIT 101
-----------------------------------------------------
City | UPPER CHICHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19061-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-768-6762
-----------------------------------------------------
Fax | 855-772-4748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 BENFIELD BLVD STE 250
-----------------------------------------------------
City | MILLERSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21108-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-905-3261
-----------------------------------------------------
Fax | 855-772-4748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RAYMOND JOSEPH KOSTKOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-991-0044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------