Provider Demographics
NPI:1598052466
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:NESTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-428-1500
Mailing Address - Street 1:618 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-2721
Mailing Address - Country:US
Mailing Address - Phone:928-428-1500
Mailing Address - Fax:
Practice Address - Street 1:618 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2721
Practice Address - Country:US
Practice Address - Phone:928-428-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3915261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788771Medicaid
AZ788771Medicaid
Z137976Medicare PIN