Provider Demographics
NPI:1568886000
Name:WAYNE COMMUNITY HEALTH CENTERS INC
Entity Type:Organization
Organization Name:WAYNE COMMUNITY HEALTH CENTERS INC
Other - Org Name:KAZAN IVAN W MEMORIAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-425-3744
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:BICKNELL
Mailing Address - State:UT
Mailing Address - Zip Code:84715-0303
Mailing Address - Country:US
Mailing Address - Phone:435-425-3744
Mailing Address - Fax:435-425-3785
Practice Address - Street 1:570 E MOQUI LN
Practice Address - Street 2:
Practice Address - City:ESCALANTE
Practice Address - State:UT
Practice Address - Zip Code:84726-0276
Practice Address - Country:US
Practice Address - Phone:435-826-4374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE COMMUNITY HEALTH CENTERS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-04
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055193OtherMEDICARE PART B -
UT461841Medicare Oscar/Certification