Provider Demographics
NPI:1093247082
Name:BLACKHAWK MANGUM, LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM, LLC
Other - Org Name:ALTUS RADIOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-782-3353
Mailing Address - Street 1:3000 N MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1348
Mailing Address - Country:US
Mailing Address - Phone:580-477-2674
Mailing Address - Fax:580-477-2598
Practice Address - Street 1:1 WICKERSHAM ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-9117
Practice Address - Country:US
Practice Address - Phone:580-782-3353
Practice Address - Fax:580-782-5944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKHAWK MANGUM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2208261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology