=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649933144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE LIVING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 KELLEMS DR
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-9172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-2801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 KELLEMS DR
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-9172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-2801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | WAYNE PUMFORD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-908-3464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------