Provider Demographics
NPI:1124730627
Name:BLACK CANYON COMMUNITY HEALTH CENTER INC.
Entity type:Organization
Organization Name:BLACK CANYON COMMUNITY HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-374-0200
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-0012
Mailing Address - Country:US
Mailing Address - Phone:623-374-0200
Mailing Address - Fax:623-374-5576
Practice Address - Street 1:17301 E SPRING VALLEY RD STE F
Practice Address - Street 2:
Practice Address - City:MAYER
Practice Address - State:AZ
Practice Address - Zip Code:86333-4263
Practice Address - Country:US
Practice Address - Phone:623-374-0200
Practice Address - Fax:623-374-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty