Healthcare Provider Details

I. General information

NPI: 1134568660
Provider Name (Legal Business Name): CANYONLANDS COMMUNITY HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WARD CANYON ROAD #A
CLIFTON AZ
85533
US

IV. Provider business mailing address

PO BOX 1625 827 VISTA AVE
PAGE AZ
86040-1625
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-9675
  • Fax:
Mailing address:
  • Phone: 928-645-9675
  • 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: CHRISTOPHER J HANSEN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 928-645-9675