Healthcare Provider Details

I. General information

NPI: 1508129479
Provider Name (Legal Business Name): ORLANDO DIAZ SPECIAL EDUCATOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2012
Last Update Date: 06/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 SHADY CT
BUSHKILL PA
18324-8611
US

IV. Provider business mailing address

308 SHADY CT
BUSHKILL PA
18324-8611
US

V. Phone/Fax

Practice location:
  • Phone: 570-807-3986
  • Fax:
Mailing address:
  • Phone: 570-807-3986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: