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General NPI Number Information
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NPI Number | 1790094241
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Entity Type | Organization
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Legal Business Name | CHAUNCY MONTGOMERY
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Dates
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Enumeration Date | 10/01/2010
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Last Update Date | 10/01/2010
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Provider Practice Location Address
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Address Line | 1114 JR ROLLINS RD
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City | VIDALIA
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State | GA
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Zip | 30474-9462
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Country | US
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Telephone | 912-537-4143
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Fax | 912-537-4143
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Provider Business Mailing Address
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Address Line | 1114 JR ROLLINS RD
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City | VIDALIA
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State | GA
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Zip | 30474-9462
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Country | US
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Telephone | 912-537-4143
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Fax | 912-537-4143
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | MRS. CHAUNCY DENETTE MONTGOMERY
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Credential |
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Telephone | 912-347-2399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State | GA
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