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General NPI Number Information
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NPI Number | 1922688480
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Entity Type | Individual
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Provider Name | MCKENZIE BROOKE MONTANA DO
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Gender | Female
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Dates
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Enumeration Date | 04/09/2021
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Last Update Date | 06/13/2025
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Provider Practice Location Address
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Address Line | 701 GROVE RD
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City | GREENVILLE
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State | SC
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Zip | 29605-4210
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Country | US
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Telephone | 864-455-7895
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Fax |
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Provider Business Mailing Address
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Address Line | 100 KIMEL FOREST DR
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City | WINSTON SALEM
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State | NC
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Zip | 27103-6074
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Country | US
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Telephone | 336-716-2255
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | LL83548
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 2024-01604
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License Number State | NC
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