Healthcare Provider Details

I. General information

NPI: 1790978617
Provider Name (Legal Business Name): KEITH ALLEN MONTGOMERY JR. N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11965 CACTUS RD
ADELANTO CA
92301-4906
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 270
SOUTH PASADENA CA
91030-5801
US

V. Phone/Fax

Practice location:
  • Phone: 760-561-6081
  • Fax: 877-778-9461
Mailing address:
  • Phone: 626-346-2455
  • Fax: 626-639-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number758758
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95008198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: