Provider Demographics
NPI:1699314443
Name:CORNERSTONE SUPPORTED LIVING
Entity type:Organization
Organization Name:CORNERSTONE SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-302-8366
Mailing Address - Street 1:3400 E RIVER VALLEY ST APT J202
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-2361
Mailing Address - Country:US
Mailing Address - Phone:907-302-8366
Mailing Address - Fax:208-955-5608
Practice Address - Street 1:3400 E RIVER VALLEY ST APT J202
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-2361
Practice Address - Country:US
Practice Address - Phone:907-302-8366
Practice Address - Fax:208-955-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No347C00000XTransportation ServicesPrivate Vehicle