Provider Demographics
NPI:1669441564
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:CANYONLANDS URGENT CARE
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 1:440 NORTH NAVAJO DRIVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1625
Practice Address - Country:US
Practice Address - Phone:928-645-1700
Practice Address - Fax:928-645-1701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANYONDLANDS COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
AZOTC 3854 - DOH261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ432857Medicaid
AZ=========006Medicaid
AZ031861Medicare Oscar/Certification
AZ=========006Medicaid
AZZFQ31811Medicare PIN