Provider Demographics
NPI:1013216498
Name:MONTCLAIR HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:MONTCLAIR HEALTH AND WELLNESS LLC
Other - Org Name:SPECIALTY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-212-1117
Mailing Address - Street 1:710 CORNERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091
Mailing Address - Country:US
Mailing Address - Phone:931-422-2192
Mailing Address - Fax:931-246-4233
Practice Address - Street 1:710 CORNERSVILLE RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091
Practice Address - Country:US
Practice Address - Phone:931-994-5717
Practice Address - Fax:931-246-4233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000012854363LF0000X
TNAPN0000006822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005482Medicaid