Healthcare Provider Details

I. General information

NPI: 1215144282
Provider Name (Legal Business Name): MONTGOMERY FAMILY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 S, MAIN STREET
MIDDLETON TN
38052
US

IV. Provider business mailing address

727 S, MAIN STREET
MIDDLETON TN
38052
US

V. Phone/Fax

Practice location:
  • Phone: 731-376-2804
  • Fax: 731-376-2806
Mailing address:
  • Phone: 731-376-2804
  • Fax: 731-376-2806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000005776
License Number StateTN

VIII. Authorized Official

Name: MRS. CHARLOTTE MONTGOMERY
Title or Position: OWNER
Credential: APN
Phone: 731-376-2804