Healthcare Provider Details

I. General information

NPI: 1295967131
Provider Name (Legal Business Name): CORNERSTONE HEALTH CARE RESOURCES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1699 W 4TH ST
TAHLEQUAH OK
74464-5065
US

IV. Provider business mailing address

PO BOX 2050
TAHLEQUAH OK
74465-2050
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-0040
  • Fax: 918-453-0220
Mailing address:
  • Phone: 918-453-0040
  • Fax: 918-453-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KENT J ROUNTREE
Title or Position: ADMINISTRATOR
Credential:
Phone: 918-453-0040