Healthcare Provider Details

I. General information

NPI: 1740215151
Provider Name (Legal Business Name): GEORGIA N MONTGOMERY OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6722
US

IV. Provider business mailing address

1020 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6722
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-9587
  • Fax: 505-266-2484
Mailing address:
  • Phone: 505-256-9587
  • Fax: 505-266-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: