Provider Demographics
NPI:1992737613
Name:BLACKHAWK MANGUM LLC
Entity type:Organization
Organization Name:BLACKHAWK MANGUM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-830-8529
Mailing Address - Street 1:ONE WICKERSHAM DR
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:ONE WICKERSHAM DR
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:2006-07-06
Last Update Date:2009-11-19
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
OK100699750AMedicaid
OK100699750BMedicaid
OK500522139Medicare Oscar/Certification
OK371330Medicare Oscar/Certification