Provider Demographics
NPI:1710039623
Name:CORNERSTONE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:CORNERSTONE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA FUENTE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT, CSCS
Authorized Official - Phone:732-499-4540
Mailing Address - Street 1:152 CENTRAL AVE 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066
Mailing Address - Country:US
Mailing Address - Phone:732-499-4540
Mailing Address - Fax:732-499-4577
Practice Address - Street 1:152 CENTRAL AVE 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066
Practice Address - Country:US
Practice Address - Phone:732-499-4540
Practice Address - Fax:732-499-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01170400225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ071361Medicare PIN