Basic Information
| Provider Information | |||||||||
| NPI: | 1194191601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNERSTONE CLINICAL SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 S WILLOW ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730753849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052079131 | ||||||||
| FaxNumber: | 8884113004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1408 W ELDER AVE | ||||||||
| Address2: | |||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735334022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805957000 | ||||||||
| FaxNumber: | 5805957005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5805957000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 100747400 | OK | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100747400C | 05 | OK | MEDICAID |