Healthcare Provider Details

I. General information

NPI: 1336621770
Provider Name (Legal Business Name): MAYRA EDITH SOLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2018
Last Update Date: 09/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 S. WESTERN AVE BLDG. 400
OKLAHOMA CITY OK
73139
US

IV. Provider business mailing address

6510 S. WESTERN AVE BLDG. 400
OKLAHOMA CITY OK
73139
US

V. Phone/Fax

Practice location:
  • Phone: 405-634-1497
  • Fax:
Mailing address:
  • Phone: 405-634-1497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: