Provider Demographics
NPI:1336511336
Name:EARLY INTERVENTION CORNERSTONE, INC.
Entity Type:Organization
Organization Name:EARLY INTERVENTION CORNERSTONE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:917-279-7644
Mailing Address - Street 1:98-34 ALSTYNE AVENUE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:917-279-7644
Mailing Address - Fax:
Practice Address - Street 1:98-34 ALSTYNE AVENUE
Practice Address - Street 2:FLOOR 2
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:917-279-7644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid