1598052466 NPI number — CANYONLANDS COMMUNITY HEALTH CARE

Table of content: (NPI 1598052466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598052466 NPI number — CANYONLANDS COMMUNITY HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYONLANDS COMMUNITY HEALTH CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598052466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 S CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAFFORD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85546-2721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-428-1500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAFFORD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85546-2721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-428-1500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NESTOR
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
SITE DIRECTOR
Authorized Official Telephone Number:
928-428-1500

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  3915 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 788771 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".