Healthcare Provider Details

I. General information

NPI: 1003294760
Provider Name (Legal Business Name): MRS. MARTHA MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W FARIS RD
GREENVILLE SC
29605-3061
US

IV. Provider business mailing address

112 W FARIS RD
GREENVILLE SC
29605-3061
US

V. Phone/Fax

Practice location:
  • Phone: 404-290-0296
  • Fax:
Mailing address:
  • Phone: 404-290-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number261QA0600X
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: