MEDICARE: CORNERSTONE COMMUNITY DEVELOPMENT CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1003093634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE COMMUNITY DEVELOPMENT CORPORATION

Provider Business Mailing Address
First Line	:	1395 BANCROFT AVE
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-5103
Country	:	US
Telephone Number	:	510-357-0205
Fax Number	:	510-357-0688

Provider Business Practice Location Address
First Line	:	1395 BANCROFT AVE
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94577-5103
Country	:	US
Telephone Number	:	510-357-0205
Fax Number	:	510-357-0688

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ELIZABETH VARELA
Credential	:
Telephone Number	:	510-357-0205

Provider Enumeration Date	:	01/25/2008
Last Update Date	:	01/25/2008

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