MEDICARE: D. B. MONTGOMERY CHOICE , LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center	121602	TX

General Provider Information

NPI Number	:	1922287655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D. B. MONTGOMERY CHOICE , LLC

Provider Business Mailing Address
First Line	:	4131 HARDEMAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-3636
Country	:	US
Telephone Number	:	817-534-1426
Fax Number	:	817-534-1434

Provider Business Practice Location Address
First Line	:	4131 HARDEMAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-3636
Country	:	US
Telephone Number	:	817-534-1426
Fax Number	:	817-534-1434

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CLE MONTGOMERY
Credential	:
Telephone Number	:	469-569-3762

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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