NPIMap

Organization Active NPI

Canyonlands Community Health Care

Doing business as Canyonlands Healthcare Globe

  • Federally Qualified Health Center (FQHC)
  • Globe, AZ
National Provider Identifier
1417218876
Registry record updated Sep 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
Canyonlands Healthcare Globe
Practice address
5860 South Hospital Drive
Ste 102
Globe, AZ 85501
Phone
(928) 402-0491
Fax
(928) 402-0490
NPI assigned
Jun 1, 2012
Last updated
Sep 23, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
CANYONLANDS COMMUNITY HEALTH CAREAs 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

5860 South Hospital Drive
Ste 102
Globe, AZ 85501

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
1619945904OtherAZCORPORATE NPI
933575MedicaidAZ
031811OtherAZCORPORATE PTAN

Other names 1

  • Canyonlands Healthcare Globe 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
O20120926000702 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 Practice locations: Globe, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1417218876. Details of each certification follow.

Federally qualified health center certification: CCN 031908

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 27, 2012
Last certification
Sep 27, 2012
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1975 in AZ
Enrollment address
5860 S Hospital Dr #102
Globe, AZ 85501-9449

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 Director Jul 1, 2016 2%
Marcie Larson Individual Corporate Director May 1, 2019 2%
Judith Brittain Individual Corporate DirectorBoard Member Sep 1, 2023
Holly Smith Individual Corporate OfficerCfo Jan 1, 2016
Justine Holguin Individual Other Aug 1, 2020
William Justice Individual Corporate Director Mar 25, 2015 2%
Christopher Hansen Individual Corporate OfficerCeo Jan 1, 2016 5%
W-2 Managing EmployeeCeo Jan 1, 2016 5%
Thomas Bradley Individual Corporate Director Nov 19, 2014 2%
Tom Maikowski Individual Corporate DirectorBoard Member Feb 17, 2015 2%
Paulette Leblanc Individual Corporate Director Feb 26, 2014 2%

Practitioners & affiliated clinicians

Practitioners 28

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 28

NPI Registry JSON

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

{
    "created_epoch": "1338508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632355200000",
    "number": "1417218876",
    "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": "5860 SOUTH HOSPITAL DRIVE",
            "address_2": "STE 102",
            "city": "GLOBE",
            "state": "AZ",
            "postal_code": "85501",
            "telephone_number": "928-402-0491",
            "fax_number": "928-402-0490"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "enumeration_date": "2012-06-01",
        "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": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CORPORATE NPI",
            "identifier": "1619945904",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "933575",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CORPORATE PTAN",
            "identifier": "031811",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Canyonlands Healthcare Globe",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Globe, AZ

Sources for this page

Verify at the official NPI Registry.