Provider Demographics
NPI:1861558595
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-645-9675
Mailing Address - Street 1:PO BOX 1625
Mailing Address - Street 2:827 VISTA AVENUE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1625
Mailing Address - Country:US
Mailing Address - Phone:928-645-9675
Mailing Address - Fax:928-645-2626
Practice Address - Street 1:2016 WEST 16TH STREET
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-428-1500
Practice Address - Fax:928-428-1555
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANYONLANDS COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-28
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC 4095261QF0400X
AZ261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ933583Medicaid
AZ432857Medicaid
AZ1861558595Medicare Oscar/Certification
AZZ67338Medicare UPIN
AZ432857Medicaid
AZ031846Medicare PIN
031846Medicare Oscar/Certification