Healthcare Provider Details

I. General information

NPI: 1326964503
Provider Name (Legal Business Name): KORNERSTONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 GREENWAY TER APT 1
BROOKFIELD WI
53005-6925
US

IV. Provider business mailing address

1150 GREENWAY TER APT 1
BROOKFIELD WI
53005-6925
US

V. Phone/Fax

Practice location:
  • Phone: 262-794-1229
  • Fax:
Mailing address:
  • Phone: 262-794-1229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: IRAN AMANDAH
Title or Position: OWNER/MANAGER
Credential: M.S.
Phone: 262-794-1229