Healthcare Provider Details

I. General information

NPI: 1811351703
Provider Name (Legal Business Name): BLACKHAWK MANGUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WICKERSHAM ST
MANGUM OK
73554-9117
US

IV. Provider business mailing address

1415 WATTS ST SUITE 100
SAYRE OK
73662-1310
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-3353
  • Fax: 580-782-5944
Mailing address:
  • Phone: 580-928-2044
  • Fax: 580-928-5660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN OWENS
Title or Position: OWNER
Credential:
Phone: 580-782-3353