Basic Information
Provider Information | |||||||||
NPI: | 1912251232 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORNERSTONE HEALTH CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORNERSTONE BEHAVIORAL MEDICINE @ CPED PREMIER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WESTCHESTER DR | ||||||||
Address2: | SUITE 850 | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272627008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022000 | ||||||||
FaxNumber: | 3368022534 | ||||||||
Practice Location | |||||||||
Address1: | 4515 PREMIER DR | ||||||||
Address2: | SUITE 402A | ||||||||
City: | HIGH POINT | ||||||||
State: | NC | ||||||||
PostalCode: | 272658357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368022205 | ||||||||
FaxNumber: | 3368022206 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2012 | ||||||||
LastUpdateDate: | 11/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATHIS | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3368022536 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 6008795 | 05 | NC |   | MEDICAID |