Healthcare Provider Details

I. General information

NPI: 1922870898
Provider Name (Legal Business Name): FELIX MONTESINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MULBERRY LN
JACKSONVILLE NC
28546-4548
US

IV. Provider business mailing address

114 MULBERRY LN
JACKSONVILLE NC
28546-4548
US

V. Phone/Fax

Practice location:
  • Phone: 574-215-3631
  • Fax:
Mailing address:
  • Phone: 574-215-3631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number000045856552
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: