Provider Demographics
NPI:1215214788
Name:PROVO CANYON SCHOOL
Entity Type:Organization
Organization Name:PROVO CANYON SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-223-7117
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-0340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1317 E 750 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5480
Practice Address - Country:US
Practice Address - Phone:801-227-2165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency