Provider Demographics
NPI:1447363783
Name:BLACKWELL HMA LLC
Entity type:Organization
Organization Name:BLACKWELL HMA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:710 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-3700
Mailing Address - Country:US
Mailing Address - Phone:580-363-2311
Mailing Address - Fax:
Practice Address - Street 1:710 S 13TH ST
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-3700
Practice Address - Country:US
Practice Address - Phone:580-363-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACKWELL HMA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2281275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700340CMedicaid
OK100700340AMedicaid
OK100700340AMedicaid