1881249332 NPI number — CORNERSTONE INTEGRATIVE MEDICINE

Table of content: (NPI 1881249332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881249332 NPI number — CORNERSTONE INTEGRATIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE INTEGRATIVE MEDICINE
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:
Provider Other Organization Name Type Code:
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:
1881249332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3012 SUMMIT ST STE 2675
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-3480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-326-4649
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3012 SUMMIT ST STE 2675
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-3480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-869-6740
Provider Business Practice Location Address Fax Number:
510-869-6742
Provider Enumeration Date:
08/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SHORE
Authorized Official First Name:
LORI
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
CEO PARTNER, CO-OWNER
Authorized Official Telephone Number:
510-326-4649

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346573094 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790937506 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1932538121 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1831124080 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861427684 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1770571077 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245404607 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1558678201 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003114463 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1295995256 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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