NPIMap

Organization Active NPI

Black Canyon Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Mayer, AZ
National Provider Identifier
1124730627
Registry record updated Jun 18, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BLACK CANYON COMMUNITY HEALTH CENTER, INC.
Practice address
17301 E Spring Valley Rd Ste F
Mayer, AZ 86333-4263
Phone
(623) 374-0200
Fax
(623) 374-5576
NPI assigned
Dec 16, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Randy Charles Hancock, DONPI 1467432971
Title
Ceo
Phone
(623) 374-0200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

17301 E Spring Valley Rd Ste F
Mayer, AZ 86333-4263

Mailing address

PO Box 12
Black Canyon City, AZ 85324-0012
Phone (623) 374-0200

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090812000350 AZ Part B Supplier - Clinic/Group Practice 6406900331 Receives reassigned benefits from 8 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Black Canyon City, AZ; Mayer, AZ
O20230601002988 AZ Part A Provider - Federally Qualified Health Center (FQHC) 6406900331 Practice locations: Mayer, AZ

Federally qualified health center certification: CCN 031018

Legal name
BLACK CANYON COMMUNITY HEALTH CENTER INC.
Doing business as
BLACK CANYON COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 31, 2023
Last certification
May 31, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 7, 2008 in AZ
Enrollment address
17301 E Spring Valley Rd
Ste F
Mayer, AZ 86333-4263

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Donna Gutowski Individual Corporate Director Apr 1, 2021
Gary King Individual Corporate Director Apr 1, 2021
George Passias Individual Corporate Director Apr 1, 2021
Rolf Christensen Individual Corporate Director Apr 1, 2021
Terry Anderson Individual Corporate Director Apr 1, 2021
Bettyjane Reymer Individual W-2 Managing EmployeeOffice Manager Apr 1, 2011
Rachael Nadado Individual Corporate OfficerChief Operating Officer May 29, 2017
Black Canyon Community Health Center Inc. Organization, Mayer, AZ Non-profit Operational/Managerial Control Apr 11, 2023 100%
Mark Mathern Individual Corporate Director Dec 14, 2022
Mark Richardson Individual Corporate Director Apr 1, 2021
Florence Bruemmer Individual Corporate Director Apr 1, 2021
Benjamin Hunsaker Individual Corporate Director Apr 1, 2021
Randall Hrabina Individual Corporate Director Apr 1, 2021
Debra Anderson Individual Corporate Director Apr 1, 2021
Randy C Hancock Individual Corporate OfficerChief Executive Officer Apr 1, 2008

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Black Canyon Community Health Center Inc.Black Canyon City, AZ, CCN 031013 Federally qualified health center Operational/Managerial Control (100%) Jul 1, 2008

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1671148800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1781740800000",
    "number": "1124730627",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 12",
            "city": "BLACK CANYON CITY",
            "state": "AZ",
            "postal_code": "853240012",
            "telephone_number": "623-374-0200",
            "fax_number": "623-374-5576"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17301 E SPRING VALLEY RD STE F",
            "city": "MAYER",
            "state": "AZ",
            "postal_code": "863334263",
            "telephone_number": "623-374-0200",
            "fax_number": "623-374-5576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK CANYON COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-12-16",
        "last_updated": "2026-06-18",
        "certification_date": "2026-06-18",
        "status": "A",
        "authorized_official_last_name": "HANCOCK",
        "authorized_official_first_name": "RANDY",
        "authorized_official_middle_name": "CHARLES",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "623-374-0200",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mayer, AZ

Sources for this page

Verify at the official NPI Registry.