Provider Demographics
NPI:1053553008
Name:GASTONIA CORNERSTONE CHRISTIAN CENTER INC.
Entity type:Organization
Organization Name:GASTONIA CORNERSTONE CHRISTIAN CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-867-8749
Mailing Address - Street 1:PO BOX 2074
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28053-2074
Mailing Address - Country:US
Mailing Address - Phone:704-867-8749
Mailing Address - Fax:704-869-8892
Practice Address - Street 1:400 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0441
Practice Address - Country:US
Practice Address - Phone:704-867-8749
Practice Address - Fax:704-869-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6106324251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301639BMedicaid