Healthcare Provider Details

I. General information

NPI: 1629636360
Provider Name (Legal Business Name): LAUREN E MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S SAN MARCOS ST
WHITNEY TX
76692
US

IV. Provider business mailing address

882 FM 2114
AQUILLA TX
76622-2551
US

V. Phone/Fax

Practice location:
  • Phone: 254-694-2233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2077619
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: