Healthcare Provider Details

I. General information

NPI: 1366192221
Provider Name (Legal Business Name): ALEC JUSTIN MONTEMAYOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6222 NE 74TH ST # 8158
SEATTLE WA
98115-8158
US

IV. Provider business mailing address

1039 E ELM ST
OTHELLO WA
99344-1638
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-5800
  • Fax:
Mailing address:
  • Phone: 509-989-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: