=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780239525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTAGUE VISION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 08/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1129 QUENTIN RD
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17042-6915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-272-7059
-----------------------------------------------------
Fax | 717-272-2155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 310
-----------------------------------------------------
City | CONYNGHAM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18219-0310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-687-7943
-----------------------------------------------------
Fax | 717-685-3250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PAUL R MONTAGUE
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 570-687-7943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------