1306395363 NPI number — LESLIE MONTGOMERY

Table of content: LESLIE MONTGOMERY (NPI 1306395363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306395363 NPI number — LESLIE MONTGOMERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
LESLIE
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:
MONTGOMERY
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306395363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1466 BEACH AVE APT 12A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10460-3622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-431-2880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 NOBLE AVE
Provider Second Line Business Practice Location Address:
APT 10C
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10460-3107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-431-2880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2016

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: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 814016687 . This is a "DURABLE MEDICAL EQUIPMENT SUPPLIER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com