Provider Demographics
NPI:1225362015
Name:BLACKHAWK MANGUM LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM LLC
Other - Org Name:QUARTZ MOUNTAIN MEDICAL CLINIC MANGUM NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-782-3353
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-0280
Mailing Address - Country:US
Mailing Address - Phone:580-782-3353
Mailing Address - Fax:
Practice Address - Street 1:ONE WICKERSHAM DRIVE
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health