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General NPI Number Information
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NPI Number | 1760890040
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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 | 07/30/2014
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Last Update Date | 09/08/2014
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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 | 1 WICKERSHAM ST
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City | MANGUM
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State | OK
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Zip | 73554-9117
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Country | US
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Telephone | 580-782-3353
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Fax | 580-782-5944
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Authorized Official
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Title or Position | CEO
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Name | MRS. LINDSAY CRABB
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Credential | CEO
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Telephone | 580-782-3353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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