Healthcare Provider Details

I. General information

NPI: 1497026249
Provider Name (Legal Business Name): DIANA M. MUNOZ B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. DIANA M. LEWIS

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15481 N JARVIS RD
TAHLEQUAH OK
74464-0233
US

IV. Provider business mailing address

16577 WEST CLYDE MAHER ROAD
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-822-3456
  • Fax:
Mailing address:
  • Phone: 918-822-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: