Healthcare Provider Details

I. General information

NPI: 1992737613
Provider Name (Legal Business Name): BLACKHAWK MANGUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE WICKERSHAM DR
MANGUM OK
73554-9117
US

IV. Provider business mailing address

ONE WICKERSHAM DR
MANGUM OK
73554-9117
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number2208
License Number StateOK

VIII. Authorized Official

Name: DAYNA HEINE
Title or Position: CREDENTIAL
Credential:
Phone: 979-830-8529