Provider Demographics
NPI:1689119943
Name:CORNERSTONE SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:CORNERSTONE SENIOR LIVING, LLC
Other - Org Name:CORNERSTONE RESIDENCE SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-435-6205
Mailing Address - Street 1:114 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-1302
Mailing Address - Country:US
Mailing Address - Phone:218-435-6205
Mailing Address - Fax:218-435-6336
Practice Address - Street 1:421 6TH ST NE
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8103
Practice Address - Country:US
Practice Address - Phone:218-435-6205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN381263310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility