Blackhawk Mangum LLC

Primary specialty

Critical Access HospitalTaxonomy code 282NC0060X

License

2208 Issued in OK

Legal business name

BLACKHAWK MANGUM LLC

Practice address

One Wickersham Dr
Mangum, OK 73554-9117

Phone

(580) 782-3353

Fax

(580) 782-5944

NPI assigned

Jul 6, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dayna Heine

Title

Credential

Phone

(979) 830-8529

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Quartz Mountain Medical Center Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1258588800000",
    "number": "1992737613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "ONE WICKERSHAM DR",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "735549117",
            "telephone_number": "580-782-3353",
            "fax_number": "580-782-5944"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "ONE WICKERSHAM DR",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "735549117",
            "telephone_number": "580-782-3353",
            "fax_number": "580-782-5944"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACKHAWK MANGUM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-06",
        "last_updated": "2009-11-19",
        "status": "A",
        "authorized_official_last_name": "HEINE",
        "authorized_official_first_name": "DAYNA",
        "authorized_official_title_or_position": "CREDENTIAL",
        "authorized_official_telephone_number": "979-830-8529"
    },
    "taxonomies": [
        {
            "code": "282NC0060X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Critical Access",
            "state": "OK",
            "license": "2208",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100699750A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100699750B",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Quartz Mountain Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Robert Telford Bennett, B.S.
• Russell D Berry, LPTA
• Blackhawk Mangum LLC
• Blackhawk Mangum LLC
• Blackhawk Mangum LLC
• Blackhawk Mangum, LLC
• Blackhawk Mangum, LLC
• Blackhawk Mangum, LLC
• Blackhawk Mangum, LLC
• Blackhawk Mangum, LLC

• Critical Access Hospital in Mangum, OK
• Providers in Mangum, OK by specialty
• Critical Access Hospital in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.