Healthcare Provider Details

I. General information

NPI: 1720699440
Provider Name (Legal Business Name): MR. WILLIAM MCCLELLAND MONTGOMERY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

IV. Provider business mailing address

1150 S OLIVE ST STE 1400
LOS ANGELES CA
90015-2871
US

V. Phone/Fax

Practice location:
  • Phone: 323-380-7590
  • Fax:
Mailing address:
  • Phone: 213-821-5977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: