NPIMap

Organization Active NPI

Canyonlands Community Health Care

Doing business as Chilchinbeto Clinic

  • Community Health Clinic/Center
  • Chilchinbeto, AZ
National Provider Identifier
1154380392
Registry record updated Sep 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
Chilchinbeto Clinic
Practice address
Chilchinbeto Chapter House Complex
Chilchinbeto, AZ 86033-1496
Phone
(928) 697-8154
Fax
(928) 697-8559
NPI assigned
Mar 17, 2006
Last updated
Sep 23, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
CANYONLANDS COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 23, 2021

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

Authorized official

Name
Christopher Hansen
Title
Ceo
Phone
(928) 645-9675

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X
Community Health Clinic/Center 261QC1500X AZ Primary

Addresses

Primary practice location

Chilchinbeto Chapter House Complex
Chilchinbeto, AZ 86033-1496

Mailing address

PO Box 1625
Page, AZ 86040-1625
Phone (928) 645-9675

Other identifiers 2

IdentifierTypeStateIssuer
594037MedicaidAZ
933559MedicaidAZ

Other names 1

  • Chilchinbeto Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040219000713 AZ Part B Supplier - Clinic/Group Practice 4082509591 Receives reassigned benefits from 42 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Safford, AZ; Pima, AZ; Page, AZ; Globe, AZ; Duncan, AZ; Clifton, AZ; Chilchinbito, AZ; Beaver Dam, AZ
O20090303000103 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 Practice locations: Chilchinbeto, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1154380392. Details of each certification follow.

Federally qualified health center certification: CCN 031834

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
CANYONLANDS HEALTH CARE-CHILCHINBETO
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 27, 2001
Last certification
Feb 27, 2001
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1975 in AZ
Enrollment address
Chilchinbeto Chapter House Complex
Chilchinbeto, AZ 86033

Other NPIs with the same Medicare PAC ID 10

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

Other NPIs on the same Medicare enrollment 12

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

National Provider Directory

National Provider Directory
Part of
Lake Powell Medical Cen

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Janice Lovett Individual Corporate DirectorBoard Member Jul 1, 2016
Richard Baker Individual Corporate DirectorBoard of Director Dec 16, 2016
Marcie Larson Individual Corporate DirectorBoard Member May 1, 2019
Judith Brittain Individual Corporate Director Sep 1, 2023
Holly Smith Individual Corporate Officer Nov 30, 2015
W-2 Managing EmployeeCfo Dec 2, 2015
William Justice Individual Corporate DirectorBoard of Director Dec 16, 2016
Christopher Hansen Individual Corporate OfficerCeo Jan 1, 2016
W-2 Managing Employee Jan 1, 2016
Thomas Bradley Individual Corporate DirectorBoard Member Oct 17, 2009
Tom Maikowski Individual Corporate DirectorBoard of Director Dec 16, 2016
Paulette Leblanc Individual Corporate DirectorBoard of Director Dec 16, 2016

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1142553600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632355200000",
    "number": "1154380392",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1625",
            "city": "PAGE",
            "state": "AZ",
            "postal_code": "860401625",
            "telephone_number": "928-645-9675",
            "fax_number": "928-645-2626"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "CHILCHINBETO CHAPTER HOUSE COMPLEX",
            "city": "CHILCHINBETO",
            "state": "AZ",
            "postal_code": "860331496",
            "telephone_number": "928-697-8154",
            "fax_number": "928-697-8559"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CANYONLANDS COMMUNITY HEALTH CENTER",
        "enumeration_date": "2006-03-17",
        "last_updated": "2021-09-23",
        "certification_date": "2021-09-23",
        "status": "A",
        "authorized_official_last_name": "HANSEN",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "928-645-9675"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "AZ",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "594037",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "933559",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Chilchinbeto Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chilchinbeto, AZ

Sources for this page

Verify at the official NPI Registry.