Healthcare Provider Details

I. General information

NPI: 1891862413
Provider Name (Legal Business Name): CORNER STONE RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 NELSON HWY
CHAPEL HILL NC
27517
US

IV. Provider business mailing address

1537 YORKSHIRE LANE
ROCKY MOUNT NC
27803
US

V. Phone/Fax

Practice location:
  • Phone: 919-402-8477
  • Fax:
Mailing address:
  • Phone: 252-937-7862
  • Fax: 252-451-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-336
License Number StateNC

VIII. Authorized Official

Name: MR. RONALD MACK JOHNSON
Title or Position: DIRECTOR
Credential: MBA
Phone: 919-452-9276