Basic Information
Provider Information | |||||||||
NPI: | 1134568660 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CANYONLANDS HEALTH CARE - CLIFTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1625 | ||||||||
Address2: | 827 VISTA AVE | ||||||||
City: | PAGE | ||||||||
State: | AZ | ||||||||
PostalCode: | 860401625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286459675 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 WARD CANYON ROAD | ||||||||
Address2: | #A | ||||||||
City: | CLIFTON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9286459675 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2013 | ||||||||
LastUpdateDate: | 09/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HANSEN | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9286459675 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 031811 | 01 | AZ | CORPORATE PTAN | OTHER |