Provider Demographics
NPI:1922147305
Name:BLACKHAWK MANGUM, LLC
Entity Type:Organization
Organization Name:BLACKHAWK MANGUM, LLC
Other - Org Name:MCH GRANITE FAMILY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-782-3353
Mailing Address - Street 1:ONE WICKERSHAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554
Mailing Address - Country:US
Mailing Address - Phone:580-782-3353
Mailing Address - Fax:580-782-5944
Practice Address - Street 1:417 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANITE
Practice Address - State:OK
Practice Address - Zip Code:73547
Practice Address - Country:US
Practice Address - Phone:580-535-4615
Practice Address - Fax:580-535-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2208282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID