Provider Demographics
NPI:1588694277
Name:FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH, INC.
Entity type:Organization
Organization Name:FOUR CORNERS COMMUNITY BEHAVIORAL HEALTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:435-613-2179
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0867
Mailing Address - Country:US
Mailing Address - Phone:435-637-7200
Mailing Address - Fax:435-637-2377
Practice Address - Street 1:690 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3166
Practice Address - Country:US
Practice Address - Phone:435-637-7200
Practice Address - Fax:435-637-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0405X
UT11672251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========007Medicaid
UT=========007Medicaid