Provider Demographics
NPI:1770896680
Name:PROVO CANYON SCHOOL
Entity type:Organization
Organization Name:PROVO CANYON SCHOOL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR CBO
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-223-7117
Mailing Address - Street 1:1350 E 750 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4345
Mailing Address - Country:US
Mailing Address - Phone:801-223-7117
Mailing Address - Fax:801-494-0070
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:801-223-7117
Practice Address - Fax:801-494-0070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT16006323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility