=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134568660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYONLANDS COMMUNITY HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2013
-----------------------------------------------------
Last Update Date | 09/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 WARD CANYON ROAD #A
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-645-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1625 827 VISTA AVE
-----------------------------------------------------
City | PAGE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86040-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-645-9675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | CHRISTOPHER J HANSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-645-9675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------