Basic Information
| Provider Information | |||||||||
| NPI: | 1588694277 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOUR CORNERS BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845013166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | HUNTINGTON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4356132179 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CMHC | ||||||||
| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251S00000X | 11672 | UT | Y | Agencies | Community/Behavioral Health |
No ID Information.