Provider Demographics
NPI:1679723217
Name:BLACK CANYON COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:BLACK CANYON COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-374-0200
Mailing Address - Street 1:PO BOX 1958
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-1958
Mailing Address - Country:US
Mailing Address - Phone:623-374-0200
Mailing Address - Fax:
Practice Address - Street 1:19251 E OASIS DR
Practice Address - Street 2:
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324-8878
Practice Address - Country:US
Practice Address - Phone:623-374-0200
Practice Address - Fax:623-374-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3297207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ397607Medicaid