1154451623 NPI number — LAUREL MONTANO

Table of content: LAUREL MONTANO (NPI 1154451623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154451623 NPI number — LAUREL MONTANO

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154451623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28593 ROAD N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOLORES
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81323-9349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-565-9895
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 W NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTEZ
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81321-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-565-3056
Provider Business Practice Location Address Fax Number:
970-565-0647
Provider Enumeration Date:
03/06/2007

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: 163WC1500X , with the licence number:  62771 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07627714 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com