Provider Demographics
NPI:1891142071
Name:WAYNE COMMUNITY HEALTH CENTERS INC.
Entity Type:Organization
Organization Name:WAYNE COMMUNITY HEALTH CENTERS INC.
Other - Org Name:SOUTHWEST/WCHC MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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:WAYNE COMMUNITY HEALTH CENTERS INC.
Mailing Address - City:BICKNELL
Mailing Address - State:UT
Mailing Address - Zip Code:84715-0303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 EAST CENTER STREET
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-826-4374
Practice Address - Fax:435-826-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
UT362182-3501261QF0400X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055193OtherMEDICARE PART B OSCAR