Healthcare Provider Details

I. General information

NPI: 1851234975
Provider Name (Legal Business Name): CORNERSTONE WELLNESS AND RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 LOMAX ST
IDAHO FALLS ID
83401-2634
US

IV. Provider business mailing address

522 LOMAX ST
IDAHO FALLS ID
83401-2634
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-9111
  • Fax: 208-557-9111
Mailing address:
  • Phone: 208-557-9111
  • Fax: 208-557-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEREMY MANWARING
Title or Position: MANAGING MEMBER
Credential:
Phone: 208-317-9912