Provider Demographics
NPI:1417218876
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:CANYONLANDS HEALTHCARE GLOBE
Other - Org Type:Doing Business As
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:
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 1:5860 SOUTH HOSPITAL DRIVE
Practice Address - Street 2:STE 102
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-402-0491
Practice Address - Fax:928-402-0490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANYONLANDS COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-01
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ031811OtherCORPORATE PTAN
AZ1619945904OtherCORPORATE NPI
AZ933575Medicaid
AZ031811OtherCORPORATE PTAN