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General NPI Number Information
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NPI Number | 1720517923
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Entity Type | Organization
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Legal Business Name | CORNERSTONE RESTORATION AND TRAINING SERVICES
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Dates
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Enumeration Date | 06/09/2017
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 1700 BLAIR ST
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City | RICHMOND
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State | VA
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Zip | 23220-6406
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Country | US
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Telephone | 804-852-7645
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Fax |
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Provider Business Mailing Address
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Address Line | 4411 WISTAR RD
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City | HENRICO
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State | VA
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Zip | 23228-2640
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Country | US
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Telephone | 804-852-7645
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ELLIS O. HENDERSON
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Credential | ED.D, M.DIV
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Telephone | 804-852-7645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 0904006909
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License Number State | VA
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