Provider Demographics
NPI:1619028313
Name:CORNERSTONE HOSPICE & PALLIATIVE CARE INC
Entity Type:Organization
Organization Name:CORNERSTONE HOSPICE & PALLIATIVE CARE INC
Other - Org Name:HOSPICE OF LAKE & SUMTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-343-1341
Mailing Address - Street 1:2445 LANE PARK RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9648
Mailing Address - Country:US
Mailing Address - Phone:352-343-1341
Mailing Address - Fax:352-343-0325
Practice Address - Street 1:2445 LANE PARK RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-9648
Practice Address - Country:US
Practice Address - Phone:352-343-1341
Practice Address - Fax:352-343-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5019096251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL087526100Medicaid
U30OtherBLUE CROSSBLUE SHIELD
101525Medicare ID - Type Unspecified
FL087526100Medicaid