Healthcare Provider Details

I. General information

NPI: 1952427171
Provider Name (Legal Business Name): CORNERSTONE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10464 E NORTHWEST HWY
DALLAS TX
75238-4608
US

IV. Provider business mailing address

10464 E NORTHWEST HWY
DALLAS TX
75238-4608
US

V. Phone/Fax

Practice location:
  • Phone: 214-341-9373
  • Fax: 214-341-0620
Mailing address:
  • Phone: 214-341-9373
  • Fax: 214-341-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4765
License Number StateTX

VIII. Authorized Official

Name: LAURENCE SMITH
Title or Position: PRESIDENT
Credential:
Phone: 214-341-9373