Provider Demographics
NPI:1083821011
Name:SAC & FOX NATION
Entity Type:Organization
Organization Name:SAC & FOX NATION
Other - Org Name:BLACK HAWK HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEDORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-968-9531
Mailing Address - Street 1:5406 NBU
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864
Mailing Address - Country:US
Mailing Address - Phone:918-968-9531
Mailing Address - Fax:918-968-0113
Practice Address - Street 1:RR 2 BOX 247
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-9652
Practice Address - Country:US
Practice Address - Phone:918-968-9531
Practice Address - Fax:918-968-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0069265261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care