MEDICARE: MONTGOMERY COUNTY BOARD OF EDUCATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1578633418
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY COUNTY BOARD OF EDUCATION

Provider Business Mailing Address
First Line	:	1100 EDGEWOOD DR
Second Line	:	EAST CENTRAL GLRS
City	:	DUBLIN
State	:	GA
Zip	:	31021-5522
Country	:	US
Telephone Number	:	478-275-1018
Fax Number	:	478-296-7766

Provider Business Practice Location Address
First Line	:	403 FULTON ST
Second Line	:
City	:	MOUNT VERNON
State	:	GA
Zip	:	30445
Country	:	US
Telephone Number	:	912-583-2279
Fax Number	:

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	DALE C CLARK
Credential	:
Telephone Number	:	912-583-2279

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	08/22/2020

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Directions to “MONTGOMERY COUNTY BOARD OF EDUCATION ” Practice Location

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