MEDICARE: CORNER CANYON RECOVERY, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor
4	1041C0700X	Clinical Social Worker
5	106H00000X	Marriage & Family Therapist
6	133N00000X	Nutritionist
7	133V00000X	Registered Dietitian
8	163W00000X	Registered Nurse
9	171M00000X	Case Manager/Care Coordinator
10	261QM1300X	Multi-Specialty Clinic/Center
11	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
12	324500000X	Substance Abuse Rehabilitation Facility
13	363LA2100X	Acute Care Nurse Practitioner
14	323P00000X	Psychiatric Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107411	OTHER	UT	STATE LICENSE
2	107410	OTHER	UT	STATE LICENSE
3	107170	OTHER	UT	STATE LICENSE

General Provider Information

NPI Number	:	1730843293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNER CANYON RECOVERY, LLC

Provider Business Mailing Address
First Line	:	13020 S FORT ST
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-9294
Country	:	US
Telephone Number	:	801-994-1849
Fax Number	:	801-384-0820

Provider Business Practice Location Address
First Line	:	13020 S FORT ST
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-9294
Country	:	US
Telephone Number	:	801-994-6735
Fax Number	:	801-384-0820

Authorized Official
Title or Position	:	CHIEF PEOPLE OFFICER
Name	:	MR. BRADLEY RANDALL CHRISTENSEN
Credential	:
Telephone Number	:	801-994-6735

Provider Enumeration Date	:	10/29/2021
Last Update Date	:	02/13/2025

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