Provider Demographics
NPI:1811351703
Name:BLACKHAWK MANGUM, LLC
Entity type:Organization
Organization Name:BLACKHAWK MANGUM, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:580-782-3353
Mailing Address - Street 1:1415 WATTS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAYRE
Mailing Address - State:OK
Mailing Address - Zip Code:73662-1310
Mailing Address - Country:US
Mailing Address - Phone:580-928-2044
Mailing Address - Fax:580-928-5660
Practice Address - Street 1:1 WICKERSHAM ST
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:580-782-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center