Provider Demographics
NPI:1679966709
Name:BLACKHAWK MANGUM LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM LLC
Other - Org Name:QUARTZ MOUNTAIN MEDICAL CENTER ALTUS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-782-3353
Mailing Address - Street 1:1 WICKERSHAM ST
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-9117
Mailing Address - Country:US
Mailing Address - Phone:580-782-3353
Mailing Address - Fax:580-782-5944
Practice Address - Street 1:3000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1348
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:2015-03-13
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center