Provider Demographics
NPI:1619265071
Name:CORNERSTONE DIAGNOSTICS INC
Entity Type:Organization
Organization Name:CORNERSTONE DIAGNOSTICS INC
Other - Org Name:PREMIERTOX LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-412-8330
Mailing Address - Street 1:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-1240
Mailing Address - Country:US
Mailing Address - Phone:877-412-8330
Mailing Address - Fax:844-982-0300
Practice Address - Street 1:1814 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1229
Practice Address - Country:US
Practice Address - Phone:877-412-8330
Practice Address - Fax:844-982-0300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNERSTONE DIAGNOSTICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-19
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
KY200322291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100342300Medicaid