=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861914129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGUERITE GRUMP MONTJOY ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1921 S NEVADA ST
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-6417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-585-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1921 S NEVADA ST
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92054-6417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-585-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000028314
-----------------------------------------------------
License Number State |
-----------------------------------------------------