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General NPI Number Information
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NPI Number | 1295146793
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Entity Type | Individual
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Provider Name | EDILBERTO MONTENEGRO SR.
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Gender | Male
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Dates
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Enumeration Date | 05/19/2014
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Last Update Date | 05/19/2014
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Provider Practice Location Address
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Address Line | 5376 LAMBERT DR APT A APT A
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City | NORCROSS
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State | GA
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Zip | 30093-4864
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Country | US
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Telephone | 470-362-9008
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Fax | 678-400-7896
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Provider Business Mailing Address
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Address Line | 5376 A LAMBERT DR APT A
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City | NORCROSS
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State | GA
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Zip | 30093
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Country | US
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Telephone | 470-362-9008
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Fax | 678-400-7896
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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