Healthcare Provider Details

I. General information

NPI: 1053438309
Provider Name (Legal Business Name): MICHAEL LAWRENCE MONTEZ MS, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST. USC UNIVERSITY HOSPITAL SPORTS MED.
LOS ANGELES CA
90033
US

IV. Provider business mailing address

4317 E 4TH ST APT 4
LONG BEACH CA
90814-0952
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5226
  • Fax: 323-442-8750
Mailing address:
  • Phone: 562-930-9049
  • Fax: 323-442-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number02042142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: