Provider Demographics
NPI:1164048492
Name:FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC
Entity Type:Organization
Organization Name:FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-7200
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0867
Mailing Address - Country:US
Mailing Address - Phone:435-637-7200
Mailing Address - Fax:435-637-2377
Practice Address - Street 1:77 S 600 E
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3174
Practice Address - Country:US
Practice Address - Phone:435-637-7289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No3336C0002XSuppliersPharmacyClinic Pharmacy