Provider Demographics
NPI:1740588441
Name:CORNER CANYON CHIROPRACTIC
Entity Type:Organization
Organization Name:CORNER CANYON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:LESUEUR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-553-9691
Mailing Address - Street 1:1136 DRAPER PKWY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9095
Mailing Address - Country:US
Mailing Address - Phone:801-553-9691
Mailing Address - Fax:801-571-4288
Practice Address - Street 1:1136 DRAPER PKWY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9095
Practice Address - Country:US
Practice Address - Phone:801-553-9691
Practice Address - Fax:801-571-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7416390-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty