Healthcare Provider Details

I. General information

NPI: 1316911761
Provider Name (Legal Business Name): RAPHAEL MARTIN MONTAG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 7TH ST
BOONE IA
50036
US

IV. Provider business mailing address

806 7TH ST
BOONE IA
50036
US

V. Phone/Fax

Practice location:
  • Phone: 515-432-6524
  • Fax:
Mailing address:
  • Phone: 515-432-6524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number04778
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: