MEDICARE: BLACKHAWK MANGUM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NC0060X	Critical Access Hospital	2208	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992737613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKHAWK MANGUM LLC

Provider Business Mailing Address
First Line	:	ONE WICKERSHAM DR
Second Line	:
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3353
Fax Number	:	580-782-5944

Provider Business Practice Location Address
First Line	:	ONE WICKERSHAM DR
Second Line	:
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3353
Fax Number	:	580-782-5944

Authorized Official
Title or Position	:	CREDENTIAL
Name	:	DAYNA HEINE
Credential	:
Telephone Number	:	979-830-8529

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	11/19/2009

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Directions to “BLACKHAWK MANGUM LLC ” Practice Location

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