Provider Demographics
NPI:1689851016
Name:CORNERSTONE COMMUNITY LIVING INC.
Entity type:Organization
Organization Name:CORNERSTONE COMMUNITY LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:ELIJAH
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PROVIDER
Authorized Official - Phone:281-687-2173
Mailing Address - Street 1:5918 HAVENWOODS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77066-2335
Mailing Address - Country:US
Mailing Address - Phone:281-687-2173
Mailing Address - Fax:281-580-4962
Practice Address - Street 1:5918 HAVENWOODS DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77066-2335
Practice Address - Country:US
Practice Address - Phone:281-687-2173
Practice Address - Fax:281-580-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization