Healthcare Provider Details

I. General information

NPI: 1164048492
Provider Name (Legal Business Name): FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 S 600 E
PRICE UT
84501-3174
US

IV. Provider business mailing address

PO BOX 867
PRICE UT
84501-0867
US

V. Phone/Fax

Practice location:
  • Phone: 435-637-7289
  • Fax:
Mailing address:
  • Phone: 435-637-7200
  • Fax: 435-637-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEANIE WILLSON
Title or Position: CFO
Credential:
Phone: 435-637-7200