Provider Demographics
NPI:1891862413
Name:CORNER STONE RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:CORNER STONE RESIDENTIAL CARE, LLC
Other - Org Name:LIMITED LIABILITY CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MACK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:919-452-9276
Mailing Address - Street 1:1537 YORKSHIRE LANE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803
Mailing Address - Country:US
Mailing Address - Phone:252-937-7862
Mailing Address - Fax:252-451-4111
Practice Address - Street 1:2316 NELSON HWY
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517
Practice Address - Country:US
Practice Address - Phone:919-402-8477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL-032-336320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603843Medicaid