Provider Demographics
NPI:1649771775
Name:CORNISH, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CORNISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:CORNISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:420 E SOUTH TEMPLE STE 420
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1345
Mailing Address - Country:US
Mailing Address - Phone:801-322-3222
Mailing Address - Fax:
Practice Address - Street 1:420 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 420
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111
Practice Address - Country:US
Practice Address - Phone:801-322-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator