1255633855 NPI number — SANDRA KAY MONTGOMERY SANDRA MONTGOMERY

Table of content: SANDRA KAY MONTGOMERY SANDRA MONTGOMERY (NPI 1255633855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255633855 NPI number — SANDRA KAY MONTGOMERY SANDRA MONTGOMERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
SANDRA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SANDRA MONTGOMERY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONTGOMERY
Provider Other First Name:
SANDRA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SANDRA MONTGOMERY
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255633855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4314 W 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44144-2838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-877-7566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10110 SOUTH
Provider Second Line Business Practice Location Address:
7650 EAST
Provider Business Practice Location Address City Name:
CROW AGENCY
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-638-3500
Provider Business Practice Location Address Fax Number:
406-638-3382
Provider Enumeration Date:
12/02/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN 115121 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)