Provider Demographics
NPI:1578634648
Name:CORNERSTONE TREATMENT CENTER PA
Entity Type:Organization
Organization Name:CORNERSTONE TREATMENT CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:828-327-2275
Mailing Address - Street 1:11 9TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3739
Mailing Address - Country:US
Mailing Address - Phone:828-327-2275
Mailing Address - Fax:
Practice Address - Street 1:11 9TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3739
Practice Address - Country:US
Practice Address - Phone:828-327-2275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS45977Medicare UPIN