Provider Demographics
NPI:1720517923
Name:CORNERSTONE RESTORATION AND TRAINING SERVICES
Entity Type:Organization
Organization Name:CORNERSTONE RESTORATION AND TRAINING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:O
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, MDIV
Authorized Official - Phone:804-852-7645
Mailing Address - Street 1:4411 WISTAR RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-2640
Mailing Address - Country:US
Mailing Address - Phone:804-852-7645
Mailing Address - Fax:
Practice Address - Street 1:1700 BLAIR ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-6406
Practice Address - Country:US
Practice Address - Phone:804-852-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-09
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904006909261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========Medicaid