=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508057431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIANA V. MONTGOMERY,O.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 08/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 RICHMOND RD # 64
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-223-6508
-----------------------------------------------------
Fax | 903-223-6589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 RICHMOND RD # 64
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-223-6508
-----------------------------------------------------
Fax | 903-223-6589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTIANA VANZANT MONTGOMERY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 903-223-6508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5543T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------