Healthcare Provider Details

I. General information

NPI: 1790706851
Provider Name (Legal Business Name): BLACKWELL HMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S 13TH ST
BLACKWELL OK
74631-3700
US

IV. Provider business mailing address

710 S 13TH ST
BLACKWELL OK
74631-3700
US

V. Phone/Fax

Practice location:
  • Phone: 580-363-2311
  • Fax:
Mailing address:
  • Phone: 580-363-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number7335
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number2281
License Number StateOK

VIII. Authorized Official

Name: LAURIE HOLTSFORD
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-465-7466