Healthcare Provider Details

I. General information

NPI: 1083090559
Provider Name (Legal Business Name): CORNERSTONE COMMUNITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 N RIVER RD
WATERFORD WI
53185-5082
US

IV. Provider business mailing address

2953 N RIVER RD
WATERFORD WI
53185-5082
US

V. Phone/Fax

Practice location:
  • Phone: 262-744-1473
  • Fax: 262-514-3485
Mailing address:
  • Phone: 262-744-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 14
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 15
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHAWNA ROHDA
Title or Position: OWNER
Credential:
Phone: 262-744-1473