Healthcare Provider Details

I. General information

NPI: 1790094241
Provider Name (Legal Business Name): CHAUNCY MONTGOMERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 JR ROLLINS RD
VIDALIA GA
30474-9462
US

IV. Provider business mailing address

1114 JR ROLLINS RD
VIDALIA GA
30474-9462
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-4143
  • Fax: 912-537-4143
Mailing address:
  • Phone: 912-537-4143
  • Fax: 912-537-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. CHAUNCY DENETTE MONTGOMERY
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 912-347-2399