Provider Demographics
NPI:1043950868
Name:CORNERSTONE ADDICTION RECOVERY SERVICES LLC
Entity Type:Organization
Organization Name:CORNERSTONE ADDICTION RECOVERY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:971-312-2091
Mailing Address - Street 1:155 NE COURT ST UNIT 798
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-0656
Mailing Address - Country:US
Mailing Address - Phone:971-312-2091
Mailing Address - Fax:971-256-8853
Practice Address - Street 1:185 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1934
Practice Address - Country:US
Practice Address - Phone:971-312-2091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1124440813Medicaid