MEDICARE: CORNERSTONE COMMUNITY LIVING INC.

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1689851016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE COMMUNITY LIVING INC.

Provider Business Mailing Address
First Line	:	5918 HAVENWOODS DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77066-2335
Country	:	US
Telephone Number	:	281-687-2173
Fax Number	:	281-580-4962

Provider Business Practice Location Address
First Line	:	5918 HAVENWOODS DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77066-2335
Country	:	US
Telephone Number	:	281-687-2173
Fax Number	:	281-580-4962

Authorized Official
Title or Position	:	DIRECTOR PROGRAM MANAGER
Name	:	MR. SPENCER ELIJAH JACKSON JR.
Credential	:	PROVIDER
Telephone Number	:	281-687-2173

Provider Enumeration Date	:	01/29/2008
Last Update Date	:	01/29/2008

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