Healthcare Provider Details

I. General information

NPI: 1114850476
Provider Name (Legal Business Name): CORNERSTONE INTEGRATED HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86B MARTIN LN
MORIARTY NM
87035-5605
US

IV. Provider business mailing address

86B MARTIN LN
MORIARTY NM
87035-5605
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-8758
  • Fax: 505-295-6877
Mailing address:
  • Phone: 505-249-8758
  • Fax: 505-295-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN DUANE COGBURN
Title or Position: OWNER
Credential: FNP
Phone: 505-249-8758