MEDICARE: CORNER STONE RESIDENTIAL CARE, LLC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL-032-336	NC
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891862413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNER STONE RESIDENTIAL CARE, LLC

Provider Business Mailing Address
First Line	:	1537 YORKSHIRE LANE
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27803
Country	:	US
Telephone Number	:	252-937-7862
Fax Number	:	252-451-4111

Provider Business Practice Location Address
First Line	:	2316 NELSON HWY
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27517
Country	:	US
Telephone Number	:	919-402-8477
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. RONALD MACK JOHNSON
Credential	:	MBA
Telephone Number	:	919-452-9276

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	11/03/2009

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