NPIMap

Organization Active NPI

Canyonlands Community Health Care

  • Family Medicine Physician
  • Page, AZ
National Provider Identifier
1609966860
Registry record updated Sep 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CANYONLANDS COMMUNITY HEALTH CARE
Practice address
827 Vista Avenue
Page, AZ 86040-1625
Phone
(928) 645-9675
Fax
(928) 645-3862
NPI assigned
Oct 16, 2006
Last updated
Sep 23, 2021By the provider in NPPES
Organization subpart
No

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 J Hansen
Title
Ceo
Phone
(928) 645-9675

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X AZ
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X AZ Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X AZ
Obstetrics & Gynecology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207V00000X AZ
Medical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AM0700X AZ
Surgical Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363AS0400X AZ
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X AZ

Addresses

Primary practice location

827 Vista Avenue
Page, AZ 86040-1625

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
432857MedicaidAZ

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ6 enrollments

Enrollment records 6

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
Practice locations: Safford, AZ; Pima, AZ; Page, AZ; Globe, AZ; Duncan, AZ; Clifton, AZ; Chilchinbito, AZ; Beaver Dam, AZ
O20070213000663 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Page, AZ
O20071127000397 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Safford, AZ
O20071127000636 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Duncan, AZ
O20090225000408 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 Practice locations: Page, AZ
O20141205000423 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Clifton, AZ

NPI to CCN mapping 5

The Medicare certification numbers (CCNs) connected to NPI 1609966860. Details of each certification follow.

Federally qualified health center certification: CCN 031861

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 28, 2007
Last certification
Mar 28, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 6, 1975 in AZ
Enrollment address
440 N Navajo Dr
Page, AZ 86040-1625

Federally qualified health center certification: CCN 031846

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
CANYONLANDS HEALTHCARE-SAFFORD
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 2, 2004
Last certification
Dec 2, 2004
Ownership / control type
For profit – corporation
Most recent change of ownership
Apr 1, 2006 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1975 in AZ
Enrollment address
2016 W 16TH St
Safford, AZ 85546-4026

Federally qualified health center certification: CCN 031848

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
CANYONLANDS HEALTHCARE-DUNCAN
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 24, 2005
Last certification
Jun 24, 2005
Ownership / control type
For profit – corporation
Most recent change of ownership
Apr 1, 2006 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Feb 6, 1975 in AZ
Enrollment address
227 Main St
Duncan, AZ 85534-9701

Federally qualified health center certification: CCN 031811

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
LAKE POWELL MEDICAL CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1975 in AZ
Enrollment address
467 Vista Ave
Page, AZ 86040-1625

Federally qualified health center certification: CCN 031920

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
CANYONLANDS HEALTHCARE CLIFTON
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 4, 2014
Last certification
Dec 4, 2014
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Incorporated
Feb 6, 1975 in AZ
Enrollment address
10A Ward Canyon Rd
Clifton, AZ 85533-8233

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

Ownership & related parties

All disclosed owners & managing parties 11

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
Other Jul 1, 2016
Corporate Director Jul 1, 2016
Marcie Larson Individual Corporate DirectorBoard Member May 1, 2019
Other May 1, 2019
Judith Brittain Individual Corporate DirectorBoard Member Sep 1, 2023
Corporate Director Sep 1, 2023
Holly Smith Individual Corporate OfficerCfo Jan 1, 2016
W-2 Managing EmployeeCfo Jan 1, 2016
Corporate Officer Nov 30, 2015
W-2 Managing EmployeeCfo Dec 2, 2015
Corporate OfficerCfo Jan 1, 2016 5%
Justine Holguin Individual Corporate Director Jul 1, 2016
Other Aug 1, 2020
Corporate Director Aug 1, 2020
William Justice Individual Corporate Director Dec 16, 2016
Corporate DirectorBoard of Director Dec 16, 2016
Other Mar 25, 2015
Christopher Hansen Individual Corporate OfficerCeo Jan 1, 2015 5%
W-2 Managing EmployeeCeo Jan 1, 2016
Corporate OfficerCeo Jan 1, 2016
5% Or Greater Indirect Ownership InterestCeo Jan 1, 2016
W-2 Managing Employee Jan 1, 2016 5%
Thomas Bradley Individual Corporate DirectorDirector Oct 17, 2009
Corporate DirectorBoard of Director Oct 17, 2009
Other Nov 19, 2014
Tom Maikowski Individual Corporate Director Dec 16, 2016
Corporate DirectorBoard of Director Dec 16, 2016
Other Feb 17, 2015
Paulette Leblanc Individual Corporate Director Dec 16, 2016
Corporate DirectorBoard of Director Dec 16, 2016
Other Feb 26, 2014
Richard Baker Individual Corporate Director Dec 16, 2016
Corporate DirectorBoard Director Dec 16, 2016

Practitioners & affiliated clinicians

Practitioners 44

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 44

NPI Registry JSON

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

{
    "created_epoch": "1160956800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632355200000",
    "number": "1609966860",
    "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": "928-645-3030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "827 VISTA AVENUE",
            "city": "PAGE",
            "state": "AZ",
            "postal_code": "860401625",
            "telephone_number": "928-645-9675",
            "fax_number": "928-645-3862"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-16",
        "last_updated": "2021-09-23",
        "certification_date": "2021-09-23",
        "status": "A",
        "authorized_official_last_name": "HANSEN",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "928-645-9675"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Medical",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "AZ",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "432857",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Page, AZ

Sources for this page

Verify at the official NPI Registry.