Healthcare Provider Details

I. General information

NPI: 1891142071
Provider Name (Legal Business Name): WAYNE COMMUNITY HEALTH CENTERS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 EAST CENTER STREET
PANGUITCH UT
84759
US

IV. Provider business mailing address

PO BOX 303 WAYNE COMMUNITY HEALTH CENTERS INC.
BICKNELL UT
84715-0303
US

V. Phone/Fax

Practice location:
  • Phone: 435-826-4374
  • Fax: 435-826-4354
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number362182-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number362182-3501
License Number StateUT

VIII. Authorized Official

Name: EVAN CHRISTENSEN
Title or Position: CEO
Credential:
Phone: 435-425-3744