Provider Demographics
NPI:1699072405
Name:CORNERSTONE PHYSICAL THERAPY
Entity type:Organization
Organization Name:CORNERSTONE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WHITLOW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-216-7910
Mailing Address - Street 1:54 LUMPKIN CAMPGROUND RD S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6196
Mailing Address - Country:US
Mailing Address - Phone:706-216-7910
Mailing Address - Fax:706-216-7909
Practice Address - Street 1:54 LUMPKIN CAMPGROUND RD S
Practice Address - Street 2:SUITE 100
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6196
Practice Address - Country:US
Practice Address - Phone:706-216-7910
Practice Address - Fax:706-216-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1417006826OtherINDIVIDUAL NPI
GA000762187DMedicaid
GA000762187DMedicaid
GA1417006826OtherINDIVIDUAL NPI