Healthcare Provider Details

I. General information

NPI: 1033388509
Provider Name (Legal Business Name): BLACKHAWK MANGUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 SOUTH LOUIS TITTLE
MANGUM OK
73554
US

IV. Provider business mailing address

PO BOX 280
MANGUM OK
73554-0280
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-2113
  • Fax: 580-782-2141
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2208
License Number StateOK

VIII. Authorized Official

Name: SHANA DAVENPORT
Title or Position: INSURANCE CREDENTIALING SUPERVISOR
Credential:
Phone: 512-681-3460