Healthcare Provider Details

I. General information

NPI: 1740910488
Provider Name (Legal Business Name): VIRGINIA MONTELONGO OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118-5798
US

IV. Provider business mailing address

120 BLUEFIELD DR
SLIDELL LA
70458-1228
US

V. Phone/Fax

Practice location:
  • Phone: 504-896-2888
  • Fax:
Mailing address:
  • Phone: 504-435-0488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number220419
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: