Provider Demographics
NPI:1245531995
Name:CORNERSTONE II
Entity type:Organization
Organization Name:CORNERSTONE II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-317-4433
Mailing Address - Street 1:P.O. BOX 277
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49026
Mailing Address - Country:US
Mailing Address - Phone:269-628-2100
Mailing Address - Fax:269-628-2121
Practice Address - Street 1:22722 W M 43
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9208
Practice Address - Country:US
Practice Address - Phone:269-668-7419
Practice Address - Fax:269-668-7419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS800309333320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness