BLACKHAWK MANGUM, LLC — NPI 1093247082 (Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center in MANGUM, OK)

CMS-1500 Box 24J / 33a • NPI

1093247082

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

261QR0200X (CMS 74)

Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center

Box 32 Service Location & ZIP+4

1 WICKERSHAM ST, MANGUM, OK, 73554-9117

✓ 9-Digit EDI 837 ZIP+4 (73554-9117)

Practice Phone & Referral Fax

(580) 782-3353

Fax: (580) 782-5944

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1093247082 (BLACKHAWK MANGUM, LLC) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1093247082` (NPI-2 Organization / Facility)
Provider / Legal Name	BLACKHAWK MANGUM, LLC
Plain-English Specialty	Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center NUCC Code: `261QR0200X` (Clinic/Center, Radiology)
Certifying / Licensing Body	Accreditation Association for Ambulatory Health Care (AAAHC) / CMS
Practice Location Address	1 WICKERSHAM ST, MANGUM, OK, 73554-9117
Practice Telephone / Fax	Tel: (580) 782-3353 \| Fax: (580) 782-5944
Administrative Mailing Address	3000 N MAIN ST, ALTUS, OK, 73521-1348
Enumeration & Last Sync	Enumerated: 2017-03-30 \| CMS Record Updated: 2017-03-30
Authorized Official	TOMMY JOHNSON (CEO)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

1 WICKERSHAM ST, MANGUM, OK, 73554-9117

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Plain-English Taxonomy & CMS Crosswalk (261QR0200X)

What Does Taxonomy Code 261QR0200X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 261QR0200X translates to:
"Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 74 (Radiation Therapy Center)
Certifying / Accrediting Authority: Accreditation Association for Ambulatory Health Care (AAAHC) / CMS
Clinical Scope: Same-day outpatient consultations, urgent walk-in medical care, vaccinations, and day-case diagnostic procedures.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (BLACKHAWK MANGUM, LLC)

Typical CPT / Diagnostic Procedures:

Walk-In Urgent Care Evaluation, Point-of-Care Testing & X-Ray
Same-Day Ambulatory Endoscopy, Cataract & Minor Surgical Procedures

Common Therapeutic Classes:

Outpatient Oral Antimicrobials, Analgesics, Nebulizers & Vaccines

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`261QR0200X` — Clinic/Center, Radiology Plain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center	State: OK \| License: `2208` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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BLACKHAWK MANGUM, LLC (NPI #1093247082)