MEDICARE: CITY OF MANGUM

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	324500000X	Substance Abuse Rehabilitation Facility	010	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932236205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF MANGUM

Provider Business Mailing Address
First Line	:	2 WICKERSHAM ST
Second Line	:
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3337
Fax Number	:	580-782-3338

Provider Business Practice Location Address
First Line	:	2 WICKERSHAM ST
Second Line	:	201 N. OKLAHOMA
City	:	MANGUM
State	:	OK
Zip	:	73554-9117
Country	:	US
Telephone Number	:	580-782-3337
Fax Number	:	580-782-3338

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. LOUISE B. PRICE
Credential	:
Telephone Number	:	580-782-3337

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/09/2008

Similar Medicare Providers

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Practice Location Address:

ONE WICKERSHAM DR
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73554-9117

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1619094851 — NATHANIEL DASH CADC
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1972716512 — RUSSELL D BERRY LPTA
Practice Location Address:

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1417162033 — MRS. SHELIA ANNETTE HOLMES BA
Practice Location Address:

2 WICKERSHAM ST
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1891902409 — MR. SHELLY J LARSON CADC
Practice Location Address:

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1275741290 — MR. ROBERT ALBERT MILSTEAD B.S.
Practice Location Address:

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Directions to “CITY OF MANGUM ” Practice Location

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