Healthcare Provider Details

I. General information

NPI: 1366795957
Provider Name (Legal Business Name): CORNERSTONE ADULT FAMILY HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N3445 COMO RD STOP 7
LAKE GENEVA WI
53147-2658
US

IV. Provider business mailing address

N3445 COMO RD STOP 7
LAKE GENEVA WI
53147-2658
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-6302
  • Fax: 262-248-6301
Mailing address:
  • Phone: 262-248-6302
  • Fax: 262-248-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: ANDREW JACKSON
Title or Position: OWNER
Credential:
Phone: 262-248-6302