Healthcare Provider Details

I. General information

NPI: 1528302957
Provider Name (Legal Business Name): QUARTZ MOUNTIAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S LOUIS TITTLE AVE
MANGUM OK
73554-4441
US

IV. Provider business mailing address

1 WICKERSHAM ST
MANGUM OK
73554-9117
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-2113
  • Fax: 580-782-5944
Mailing address:
  • Phone: 580-782-3353
  • Fax: 580-782-5944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberR 0057113
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberR 0057113
License Number StateOK

VIII. Authorized Official

Name: MRS. LINDSAY CRABB
Title or Position: ADMINISTRATOR
Credential: CEO
Phone: 15807823353