Provider Demographics
NPI:1225364615
Name:CANYON HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CANYON HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-241-1444
Mailing Address - Street 1:165 W SOUTH ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2265
Mailing Address - Country:US
Mailing Address - Phone:844-241-1444
Mailing Address - Fax:888-891-3929
Practice Address - Street 1:165 W SOUTH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2265
Practice Address - Country:US
Practice Address - Phone:844-241-1444
Practice Address - Fax:888-891-3929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6443680001Medicare NSC