Healthcare Provider Details

I. General information

NPI: 1922108406
Provider Name (Legal Business Name): LAVERNE S MONTGOMERY MA,RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 SNAPFINGER PARK DR SUITE 110
DECATUR GA
30035-4084
US

IV. Provider business mailing address

MONTGOMERY'S STRATEGIC NUTRITION SERVICES 6066 LAKEVIEW OVERLOOK
LITHONIA GA
30038-3461
US

V. Phone/Fax

Practice location:
  • Phone: 770-981-2211
  • Fax: 770-981-0208
Mailing address:
  • Phone: 770-482-6594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License NumberLD000993
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD000993
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: