=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043362817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONTY MILTON MCGOWEN D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 HOSPITAL DR
-----------------------------------------------------
City | RATON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87740-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-445-0222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 HOSPITAL DR
-----------------------------------------------------
City | RATON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87740-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-445-0222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1439
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4782
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------