Basic Information
| Provider Information | |||||||||
| NPI: | 1861558595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANYONLANDS COMMUNITY HEALTH CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CANYONLANDS HEALTHCARE - SAFFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1625 | ||||||||
| Address2: | 827 VISTA AVENUE | ||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286459675 | ||||||||
| FaxNumber: | 9286452626 | ||||||||
| Practice Location | |||||||||
| Address1: | 2016 WEST 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | SAFFORD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284281500 | ||||||||
| FaxNumber: | 9284281555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| 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 | OTC 4095 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 933583 | 05 | AZ | MEDICAID | 432857 | 05 | AZ | MEDICAID |