Healthcare Provider Details

I. General information

NPI: 1700799541
Provider Name (Legal Business Name): BLACK CANYON COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 S MAIN ST
CAMP VERDE AZ
86322-7272
US

IV. Provider business mailing address

19251 E OASIS DR
BLACK CANYON CITY AZ
85324-8878
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 Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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