Provider Demographics
NPI:1417509860
Name:CANYON CARE LLC
Entity Type:Organization
Organization Name:CANYON CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIBRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-742-9820
Mailing Address - Street 1:PO BOX 8072
Mailing Address - Street 2:
Mailing Address - City:ALTA
Mailing Address - State:UT
Mailing Address - Zip Code:84092-8072
Mailing Address - Country:US
Mailing Address - Phone:801-742-2273
Mailing Address - Fax:
Practice Address - Street 1:10160 E STATE HIGHWAY 210 STE 2
Practice Address - Street 2:
Practice Address - City:ALTA
Practice Address - State:UT
Practice Address - Zip Code:84092-9509
Practice Address - Country:US
Practice Address - Phone:801-742-9820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty