Canyonlands Community Health Care
Organization Active NPI Community Health Clinic/Center · Chilchinbeto, AZ
NPI 1154380392 · NPPES record last updated Sep 23, 2021
Key facts
- NPI
- 1154380392
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Health Clinic/Center 261QC1500X
- Legal business name
- CANYONLANDS COMMUNITY HEALTH CARE
- Practice address
- Chilchinbeto Chapter House Complex
Chilchinbeto, AZ 86033-1496 - Phone
- (928) 697-8154
- Fax
- (928) 697-8559
- NPI assigned
- Mar 17, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- CANYONLANDS COMMUNITY HEALTH CENTER
Authorized official
- Name
- Christopher Hansen
- Title
- Ceo
- Phone
- (928) 645-9675
Other NPIs on the same Medicare enrollment 12
Other NPIs with the same Medicare PAC ID 10
Practitioners 40
-
Sara Kay Bennett, DNP, RNP, FNP
-
Janeen Bjork, MD
-
Ava Zabihi, LPC
-
Chris Hansen, PA-C
-
Michelle L Barker, LCSW
-
Marianne Bennett, FNP-C
-
Michelle Anne Craft, APRN-RNP, FNP-BC
-
Cassidy Lorraine Ducray, APRN
-
Micah Charles French, FNP-C
-
Rahsaan Lateef Lindsey, M.D.
-
Jilian McDermott, APRN, PMHNP-BC
-
Anida Pierson, FNP
-
Brian Savery, LPC
-
Joel Swanner, PA
-
Raymon E Darling, MD
-
Philip Hartwell, MD
-
Jeffrey Kiser, APRN
-
Brian Dwayne Lefler, PA-C
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in AZ
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
- Corporation · Non-profit
- Incorporated
- Jan 1, 1975 in AZ
- Enrollment address
- Chilchinbeto Chapter House Complex
Chilchinbeto, AZ 86033
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Janice Lovett |
Corporate Director |
Jul 1, 2016 | |
| Richard Baker |
Corporate Director |
Dec 16, 2016 | |
| Marcie Larson |
Corporate Director |
May 1, 2019 | |
| Judith Brittain |
Corporate Director | Sep 1, 2023 | |
| Holly Smith |
Corporate Officer | Nov 30, 2015 | |
| W-2 Managing Employee |
Dec 2, 2015 | ||
| William Justice |
Corporate Director |
Dec 16, 2016 | |
| Christopher Hansen |
Corporate Officer |
Jan 1, 2016 | |
| W-2 Managing Employee | Jan 1, 2016 | ||
| Thomas Bradley |
Corporate Director |
Oct 17, 2009 | |
| Tom Maikowski |
Corporate Director |
Dec 16, 2016 | |
| Paulette Leblanc |
Corporate Director |
Dec 16, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Part of
- Lake Powell Medical Center
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Community Health Clinic/Center | 261QC1500X | AZ | Yes |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 594037 | Medicaid | AZ | |
| 933559 | Medicaid | AZ |
Other names
- Chilchinbeto Clinic
Other providers in Chilchinbeto, AZ
All providers in Chilchinbeto, AZ · Community Health Clinic/Center in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 23, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.