Provider Demographics
NPI:1962468827
Name:CORNERSTONE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CORNERSTONE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANI
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:715-723-4451
Mailing Address - Street 1:224 N BRIDGE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2405
Mailing Address - Country:US
Mailing Address - Phone:715-723-4451
Mailing Address - Fax:715-723-5712
Practice Address - Street 1:224 N BRIDGE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2405
Practice Address - Country:US
Practice Address - Phone:715-723-4451
Practice Address - Fax:715-723-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QP2000X261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40420100Medicaid
WI40420100Medicaid