| Organization Name: | BLACKHAWK MANGUM, LLC |
| NPI Number: | 1033388509 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SHANA DAVENPORT (INSURANCE CREDENTIALING SUPERVISOR) |
| Mailing Address: | 118 South Louis Tittle Mangum |
| State: | OK US |
| Postal Code: | 73554 |
| Phone Number: | 5807822113 |
| Fax Number: | 5807822141 |
| NPI Enumeration Date: | 02/28/2008 |
| NPI Last Update Date: | 03/04/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | 2208 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |