Healthcare Provider Details

I. General information

NPI: 1619945904
Provider Name (Legal Business Name): CANYONLANDS COMMUNITY HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 VISTA AVENUE
PAGE AZ
86040-1625
US

IV. Provider business mailing address

PO BOX 1625
PAGE AZ
86040-1625
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-8123
  • Fax: 928-645-3862
Mailing address:
  • Phone: 928-645-9675
  • Fax: 928-645-3030

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberOTC 0127
License Number StateAZ

VIII. Authorized Official

Name: CHRISTOPHER J HANSEN
Title or Position: CEO
Credential:
Phone: 928-645-9675