Provider Demographics
NPI:1710378294
Name:BLACKHAWK MANGUM LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM LLC
Other - Org Name:ROBINSON FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-659-4467
Mailing Address - Street 1:1601 WATTS ST
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:OK
Mailing Address - Zip Code:73662-1314
Mailing Address - Country:US
Mailing Address - Phone:580-928-9933
Mailing Address - Fax:
Practice Address - Street 1:1601 WATTS ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662-1314
Practice Address - Country:US
Practice Address - Phone:580-928-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health