Healthcare Provider Details

I. General information

NPI: 1679154009
Provider Name (Legal Business Name): MONTGOMERY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 04/17/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 S BOSTON AVE STE 300
TULSA OK
74103-3311
US

IV. Provider business mailing address

621 PARALLEL AVE
KANSAS CITY KS
66101-1620
US

V. Phone/Fax

Practice location:
  • Phone: 720-472-1938
  • Fax:
Mailing address:
  • Phone: 720-472-1938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARRYL MONTGOMERY
Title or Position: MANAGER
Credential:
Phone: 720-472-1938