Healthcare Provider Details

I. General information

NPI: 1639691629
Provider Name (Legal Business Name): CORNERSTONE CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 CLARE AVE STE 101
PORTSMOUTH OH
45662-2583
US

IV. Provider business mailing address

802 CLARE AVE STE 101
PORTSMOUTH OH
45662-2583
US

V. Phone/Fax

Practice location:
  • Phone: 740-414-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number35.088677
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number35.127057
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.15280
License Number StateOH

VIII. Authorized Official

Name: LAURA MADU
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 740-414-0111