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General NPI Number Information
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NPI Number | 1710378294
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Entity Type | Organization
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Legal Business Name | BLACKHAWK MANGUM LLC
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Dates
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Enumeration Date | 02/05/2015
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Last Update Date | 02/05/2015
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Provider Practice Location Address
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Address Line | 1601 WATTS ST
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City | SAYRE
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State | OK
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Zip | 73662-1314
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Country | US
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Telephone | 580-928-9933
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 WATTS ST
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City | SAYRE
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State | OK
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Zip | 73662-1314
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Country | US
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Telephone | 580-928-9933
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN OWENS
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Credential |
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Telephone | 512-659-4467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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