Healthcare Provider Details

I. General information

NPI: 1477801090
Provider Name (Legal Business Name): CORNERSTONE RECOVERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 NW 10TH TER SUITE 610
FORT LAUDERDALE FL
33309-5940
US

IV. Provider business mailing address

3223 NW 10TH TER SUITE 610
FORT LAUDERDALE FL
33309-5940
US

V. Phone/Fax

Practice location:
  • Phone: 754-201-2265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1706AD975201
License Number StateFL

VIII. Authorized Official

Name: JOSE FLORES
Title or Position: ACCOUNT SPECIALIST
Credential:
Phone: 754-201-2265