Provider Demographics
NPI:1316563992
Name:FOUR CORNER
Entity Type:Organization
Organization Name:FOUR CORNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CASHMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD/PHD
Authorized Official - Phone:800-666-5323
Mailing Address - Street 1:PO BOX 690311
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95269-0311
Mailing Address - Country:US
Mailing Address - Phone:800-666-5323
Mailing Address - Fax:
Practice Address - Street 1:1310 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-3610
Practice Address - Country:US
Practice Address - Phone:800-666-5323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR CORNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies