Basic Information
| Provider Information | |||||||||
| NPI: | 1598052466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 618 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855462721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 618 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855462721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | NESTOR | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | SITE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9284281500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 3915 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 788771 | 05 | AZ | MEDICAID |