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General NPI Number Information
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NPI Number | 1992347512
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Entity Type | Organization
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Legal Business Name | CORNER CANYON PAIN & MEDICINE
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Dates
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Enumeration Date | 10/15/2019
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Last Update Date | 10/15/2019
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Provider Practice Location Address
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Address Line | 12176 S 1000 E STE 10
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City | DRAPER
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State | UT
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Zip | 84020-3221
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Country | US
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Telephone | 801-553-9691
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Fax | 801-571-4288
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Provider Business Mailing Address
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Address Line | 12176 S 1000 E STE 10
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City | DRAPER
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State | UT
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Zip | 84020-3221
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Country | US
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Telephone | 801-553-9691
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Fax | 801-571-4288
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Authorized Official
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Title or Position | OWNER
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Name | CARL GORDON LESUEUR
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Credential | DC
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Telephone | 801-553-9691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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