Healthcare Provider Details

I. General information

NPI: 1679723217
Provider Name (Legal Business Name): BLACK CANYON COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19251 E OASIS DR
BLACK CANYON CITY AZ
85324-8878
US

IV. Provider business mailing address

PO BOX 1958
BLACK CANYON CITY AZ
85324-1958
US

V. Phone/Fax

Practice location:
  • Phone: 623-374-0200
  • Fax: 623-374-5576
Mailing address:
  • Phone: 623-374-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3297
License Number StateAZ

VIII. Authorized Official

Name: RANDY CHARLES HANCOCK
Title or Position: CEO
Credential:
Phone: 623-374-0200