Healthcare Provider Details

I. General information

NPI: 1417509860
Provider Name (Legal Business Name): CANYON CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10160 E STATE HIGHWAY 210 STE 2
ALTA UT
84092-9509
US

IV. Provider business mailing address

PO BOX 8072
ALTA UT
84092-8072
US

V. Phone/Fax

Practice location:
  • Phone: 801-742-9820
  • Fax:
Mailing address:
  • Phone: 801-742-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH P LIBRE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 801-742-9820