1063855690 NPI number — CORNERSTONE MEDICAL SERVICES FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063855690 NPI number — CORNERSTONE MEDICAL SERVICES FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE MEDICAL SERVICES FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORNERSTONE MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063855690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S 333RD ST
Provider Second Line Business Mailing Address:
STE. 140
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-7359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-252-2095
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S 333RD ST
Provider Second Line Business Practice Location Address:
STE. 140
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-7359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-252-2095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BYEON
Authorized Official First Name:
JAI
Authorized Official Middle Name:
JUN
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
360-689-6268

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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