Provider Demographics
NPI:1780653741
Name:CANYONLANDS COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:CANYONLANDS COMMUNITY HEALTH CARE
Other - Org Name:CANYONLANDS HEALTH CARE - BEAVER DAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-645-9675
Mailing Address - Street 1:P O BOX 1625
Mailing Address - Street 2:827 VISTA AVENUE
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 1:3272 E RIO VIRGIN ROAD
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:AZ
Practice Address - Zip Code:86432-3200
Practice Address - Country:US
Practice Address - Phone:928-347-5971
Practice Address - Fax:928-347-5793
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:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 207Q00000X, 207V00000X
AZ207Q00000X, 261QC1500X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509882Medicaid
AZ594011Medicaid
AZ432857Medicaid
AZZ67338Medicare UPIN
031835Medicare PIN
AZ594011Medicaid
NV100509882Medicaid
AZZ67338Medicare PIN
AZCS0184Medicare PIN