Healthcare Provider Details

I. General information

NPI: 1497095483
Provider Name (Legal Business Name): SALVADOR JESSE MONTANEZ CADC-CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 TAVERN RD
MAMMOTH LAKES CA
93546-2619
US

IV. Provider business mailing address

PO BOX 2619
MAMMOTH LAKES CA
93546-2619
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-1740
  • Fax: 760-924-1741
Mailing address:
  • Phone: 760-924-1740
  • Fax: 760-924-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC053880518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: