MEDICARE: QUARTZ MOUNTAIN MEDICAL CENTER ANCILLARY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1841688439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUARTZ MOUNTAIN MEDICAL CENTER ANCILLARY SERVICES LLC

Provider Business Mailing Address
First Line	:	1 WICKERSHAM ST
Second Line	:
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3353
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 WATTS ST
Second Line	:
City	:	SAYRE
State	:	OK
Zip	:	73662-1310
Country	:	US
Telephone Number	:	580-928-2044
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	LINDSAY CRABB
Credential	:
Telephone Number	:	580-782-3353

Provider Enumeration Date	:	01/05/2015
Last Update Date	:	01/05/2015

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