Provider Demographics
NPI:1093986937
Name:BLACKHAWK MANGUM, LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-681-3460
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE WICKERSHAM DR
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554
Practice Address - Country:US
Practice Address - Phone:580-782-3353
Practice Address - Fax:580-782-2811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2208207P00000X, 207Q00000X, 363A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty