Provider Demographics
NPI:1528891827
Name:DIANA LEE MARTIN
Entity type:Organization
Organization Name:DIANA LEE MARTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-747-8035
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:FORT BRIDGER
Mailing Address - State:WY
Mailing Address - Zip Code:82933-0512
Mailing Address - Country:US
Mailing Address - Phone:307-747-8035
Mailing Address - Fax:
Practice Address - Street 1:2805 STATE HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:FORT BRIDGER
Practice Address - State:WY
Practice Address - Zip Code:82933
Practice Address - Country:US
Practice Address - Phone:307-747-8035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services