NPIMap

Organization Active NPI

Canyonlands Community Health Care

Doing business as Canyonlands Urgent Care

  • Community Health Clinic/Center
  • Page, AZ
National Provider Identifier
1669441564
Registry record updated Sep 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
License
OTC 3854 - DOH Issued in AZ
Legal business name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
Canyonlands Urgent Care
Practice address
440 North Navajo Drive
Page, AZ 86040-1625
Phone
(928) 645-1700
Fax
(928) 645-1701
NPI assigned
Mar 15, 2006
Last updated
Sep 23, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
CANYONDLANDS 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
Elizabeth G LathamNPI 1114995123
Title
Ceo
Phone
(928) 645-9675

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X
Community Health Clinic/Center 261QC1500X OTC 3854 - DOH AZ Primary

Addresses

Primary practice location

440 North Navajo Drive
Page, AZ 86040-1625

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
432857MedicaidAZ

Other names 1

  • Canyonlands Urgent Care 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
O20070213000663 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 1 other NPI on this enrollment
Practice locations: Page, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669441564. 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

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 Center

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
Marcie Larson Individual Corporate DirectorBoard Member May 1, 2019
Judith Brittain Individual Corporate DirectorBoard Member Sep 1, 2023
Holly Smith Individual Corporate OfficerCfo Jan 1, 2016
W-2 Managing EmployeeCfo Jan 1, 2016
Justine Holguin Individual Corporate Director Jul 1, 2016
William Justice Individual Corporate Director Dec 16, 2016
Christopher Hansen Individual Corporate OfficerCeo Jan 1, 2015 5%
W-2 Managing EmployeeCeo Jan 1, 2016
Thomas Bradley Individual Corporate DirectorDirector Oct 17, 2009
Tom Maikowski Individual Corporate Director Dec 16, 2016
Paulette Leblanc Individual Corporate Director Dec 16, 2016

Practitioners & affiliated clinicians

Practitioners 5

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": "1142380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632355200000",
    "number": "1669441564",
    "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": "440 NORTH NAVAJO DRIVE",
            "city": "PAGE",
            "state": "AZ",
            "postal_code": "860401625",
            "telephone_number": "928-645-1700",
            "fax_number": "928-645-1701"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CANYONDLANDS COMMUNITY HEALTH CARE",
        "enumeration_date": "2006-03-15",
        "last_updated": "2021-09-23",
        "certification_date": "2021-09-23",
        "status": "A",
        "authorized_official_last_name": "LATHAM",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "G",
        "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": "OTC 3854 - DOH",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "432857",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Canyonlands Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Page, AZ

Sources for this page

Verify at the official NPI Registry.