MEDICARE: TAYLOR J DIVELEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1871087304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR J DIVELEY

Provider Business Mailing Address
First Line	:	407 W SOUTH AVE
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-6133
Country	:	US
Telephone Number	:	580-308-5515
Fax Number	:	580-749-5792

Provider Business Practice Location Address
First Line	:	2225 N UNION ST.
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1536
Country	:	US
Telephone Number	:	580-308-5515
Fax Number	:	580-749-5792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2018
Last Update Date	:	06/24/2025

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Directions to “ TAYLOR J DIVELEY ” Practice Location

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