NPIMap

Organization Active NPI

Wayne Community Health Centers Inc

Doing business as Kazan Ivan W Memorial Clinic

  • Federally Qualified Health Center (FQHC)
  • Escalante, UT
National Provider Identifier
1568886000
Registry record updated Apr 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
WAYNE COMMUNITY HEALTH CENTERS INC
Doing business as
Kazan Ivan W Memorial Clinic
Practice address
570 E Moqui LN
Escalante, UT 84726-0276
Phone
(435) 826-4374
NPI assigned
Feb 4, 2014
Last updated
Apr 21, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
WAYNE COMMUNITY HEALTH CENTERS INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 21, 2021

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

Authorized official

Name
Evan Christensen
Title
Executive Director
Phone
(435) 425-3744

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Multi-Specialty Clinic/Center 261QM1300X

Addresses

Primary practice location

570 E Moqui LN
Escalante, UT 84726-0276

Mailing address

PO Box 303
Bicknell, UT 84715-0303
Phone (435) 425-3744

Other identifiers 1

IdentifierTypeStateIssuer
000055193OtherUTMEDICARE PART B -

Other names 1

  • Kazan Ivan W Memorial Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040113000649 UT Part B Supplier - Clinic/Group Practice 1254242233 Receives reassigned benefits from 27 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Bicknell, UT; Escalante, UT; Hanksville, UT; Salina, UT
O20140414001659 UT Part A Provider - Federally Qualified Health Center (FQHC) 1254242233 Practice locations: Escalante, UT

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1568886000. Details of each certification follow.

Federally qualified health center certification: CCN 461841

Legal name
WAYNE COMMUNITY HEALTH CENTERS, INC.
Doing business as
KAZAN MEMORIAL CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 14, 2014
Last certification
Apr 14, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 15, 1980 in UT
Enrollment address
570 E Moqui LN
Escalante, UT 84726-7753

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 4

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
46D0726558Kazan Clinic570 East Moqui Lane, Escalante, UT 84726Provider-performed microscopyAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Wayne Community Health Centers Inc7 organizations share this tax ID, including this one
Part of
Wayne Community Health Centers Inc

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 14

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

NameRoleSinceShare
Christy Peterson Individual Corporate Director Jan 1, 2000
Patricia Reese Individual Corporate Director Feb 1, 2017
Scott Bigler Individual Corporate Director Aug 23, 2017
Megan B New Individual Corporate Director Dec 23, 2015
Linda Rock Individual W-2 Managing Employee Dec 12, 2016
Donavan Smith Individual Corporate DirectorCeo May 1, 2023
W-2 Managing EmployeeCeo May 1, 2023
Curtis Whipple Individual Corporate Director May 23, 2018
Mike Riddle Individual Corporate Director Feb 2, 2018
Burke Torgerson Individual Corporate Director Aug 28, 2019
Clint Albrecht Individual Corporate Director Apr 24, 2019
Sally Sprouse Individual Corporate Director May 23, 2018
Janette H Hiskey Individual Corporate Director Jan 1, 2002
Donita Pace Individual Corporate Director Aug 23, 2017
Hope Johnson Individual Corporate Director Oct 24, 2018

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1391472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1618963200000",
    "number": "1568886000",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 303",
            "city": "BICKNELL",
            "state": "UT",
            "postal_code": "847150303",
            "telephone_number": "435-425-3744",
            "fax_number": "435-425-3785"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "570 E MOQUI LN",
            "city": "ESCALANTE",
            "state": "UT",
            "postal_code": "847260276",
            "telephone_number": "435-826-4374"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WAYNE COMMUNITY HEALTH CENTERS INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WAYNE COMMUNITY HEALTH CENTERS INC.",
        "enumeration_date": "2014-02-04",
        "last_updated": "2021-04-21",
        "certification_date": "2021-04-21",
        "status": "A",
        "authorized_official_last_name": "CHRISTENSEN",
        "authorized_official_first_name": "EVAN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "435-425-3744"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B -",
            "identifier": "000055193",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kazan Ivan W Memorial Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Escalante, UT

Sources for this page

Verify at the official NPI Registry.