Provider Demographics
NPI:1568430676
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:KAIBETO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:LATHAM
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:928-645-3030
Practice Address - Street 1:KAIBETO BOARDING SCHOOL DORM # 4
Practice Address - Street 2:
Practice Address - City:KAIBETO
Practice Address - State:AZ
Practice Address - Zip Code:86053-2121
Practice Address - Country:US
Practice Address - Phone:928-673-3491
Practice Address - Fax:928-673-3494
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANYONLANDS COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ432857Medicaid
AZ594045Medicaid
AZ=========006Medicaid
AZ=========006Medicaid
AZ031827Medicare Oscar/Certification
AZZFQ31811Medicare PIN