1245218718 NPI number — CORNERSTONE HEALTH CARE OF DOUGLAS, INC.

Table of content: (NPI 1245218718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245218718 NPI number — CORNERSTONE HEALTH CARE OF DOUGLAS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE HEALTH CARE OF DOUGLAS, INC.
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:
DOUGLAS NURSING HOME
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:
1245218718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2084 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILAN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38358-3515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-686-8321
Provider Business Mailing Address Fax Number:
731-686-7382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2084 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILAN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38358-3515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-686-8321
Provider Business Practice Location Address Fax Number:
731-686-7382
Provider Enumeration Date:
01/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILENSKI
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-859-2773

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  85 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 85 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0445434 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7440055 . This is a "ICF MEDICAID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".