Healthcare Provider Details

I. General information

NPI: 1124730627
Provider Name (Legal Business Name): BLACK CANYON COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17301 E SPRING VALLEY RD STE F
MAYER AZ
86333-4263
US

IV. Provider business mailing address

PO BOX 12
BLACK CANYON CITY AZ
85324-0012
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
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: DO
Phone: 623-374-0200