1093986937 NPI number — BLACKHAWK MANGUM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093986937 NPI number — BLACKHAWK MANGUM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACKHAWK MANGUM, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093986937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANGUM
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE WICKERSHAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANGUM
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-782-3353
Provider Business Practice Location Address Fax Number:
580-782-2811
Provider Enumeration Date:
03/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DAVENPORT
Authorized Official First Name:
SHANA
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
512-681-3460

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2208 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2208 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 2208 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 2208 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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