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General NPI Number Information
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NPI Number | 1740776954
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Entity Type | Organization
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Legal Business Name | MONTANO WELLNESS LLC
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 07/11/2018
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Provider Practice Location Address
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Address Line | 160 WEST ST STE 1A
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City | CROMWELL
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State | CT
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Zip | 06416-2441
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Country | US
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Telephone | 860-632-0144
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Fax | 860-632-7882
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Provider Business Mailing Address
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Address Line | 160 WEST ST STE 1A
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City | CROMWELL
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State | CT
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Zip | 06416-2441
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Country | US
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Telephone | 860-632-0144
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Fax | 860-632-7882
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Authorized Official
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Title or Position | OWNER, MEDICAL DIRECTOR
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Name | DR. CHARLES BRENDAN MONTANO
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Credential | MD
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Telephone | 860-632-0144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 016871
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License Number State | CT
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