NPIMap

Organization Active NPI

Canyonlands Community Health Care

Doing business as Canyonlands Health Care - Beaver Dam

  • Federally Qualified Health Center (FQHC)
  • Littlefield, AZ
National Provider Identifier
1780653741
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 Health Care - Beaver Dam
Practice address
3272 E Rio Virgin Road
Littlefield, AZ 86432-3200
Phone
(928) 347-5971
Fax
(928) 347-5793
NPI assigned
Mar 14, 2006
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 J Hansen
Title
Ceo
Phone
(928) 645-9675

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X
Family Medicine Physician 207Q00000X
Family Medicine Physician 207Q00000X AZ
Obstetrics & Gynecology Physician 207V00000X
Community Health Clinic/Center 261QC1500X AZ
Federally Qualified Health Center (FQHC) 261QF0400X AZ Primary

Addresses

Primary practice location

3272 E Rio Virgin Road
Littlefield, AZ 86432-3200

Mailing address

P O Box 1625
827 Vista Avenue
Page, AZ 86040-1625
Phone (928) 645-9675

Other identifiers 3

IdentifierTypeStateIssuer
100509882MedicaidNV
594011MedicaidAZ
432857MedicaidAZ

Other names 1

  • Canyonlands Health Care - Beaver Dam 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
O20090226000140 AZ Part A Provider - Federally Qualified Health Center (FQHC) 4082509591 Practice locations: Littlefield, AZ

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780653741. Details of each certification follow.

Federally qualified health center certification: CCN 031835

Legal name
CANYONLANDS COMMUNITY HEALTH CARE
Doing business as
CANYONLANDS HEALTHCARE BEAVER DAM
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
CorporationNon-profit
Incorporated
Jan 1, 1975 in AZ
Enrollment address
3272 E Rio Virgin Rd
Littlefield, AZ 86432-3200

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

Locations

2016 W 16th St
Safford, AZ 85546
Phone (520) 428-1377

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 Other Jul 1, 2016
Richard Baker Individual Corporate Director Dec 16, 2016
Marcie Larson Individual Other May 1, 2019
Judith Brittain Individual Corporate Director Sep 1, 2023
Holly Smith Individual Corporate Officer Nov 30, 2015
Justine Holguin Individual Other Aug 1, 2020
William Justice Individual Corporate Director Dec 16, 2016
Christopher Hansen Individual Corporate OfficerCeo Jan 1, 2016
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 3

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": "1142294400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1632355200000",
    "number": "1780653741",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P O BOX 1625",
            "address_2": "827 VISTA AVENUE",
            "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": "3272 E RIO VIRGIN ROAD",
            "city": "LITTLEFIELD",
            "state": "AZ",
            "postal_code": "864323200",
            "telephone_number": "928-347-5971",
            "fax_number": "928-347-5793"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CANYONLANDS COMMUNITY HEALTH CARE",
        "enumeration_date": "2006-03-14",
        "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": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "AZ",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "AZ",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100509882",
            "state": "NV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "594011",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "432857",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Canyonlands Health Care - Beaver Dam",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Littlefield, AZ

Sources for this page

Verify at the official NPI Registry.