Healthcare Provider Details

I. General information

NPI: 1174339774
Provider Name (Legal Business Name): RICHARD B MONTGOMERY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 JULESBURG LN
BENTON LA
71006-6705
US

IV. Provider business mailing address

728 JULESBURG LN
BENTON LA
71006-6705
US

V. Phone/Fax

Practice location:
  • Phone: 318-393-7638
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN113210
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: