Provider Demographics
NPI:1144422890
Name:MONTGOMERY CANCER CENTER LLC
Entity Type:Organization
Organization Name:MONTGOMERY CANCER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VENTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-273-7000
Mailing Address - Street 1:4145 CARMICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2803
Mailing Address - Country:US
Mailing Address - Phone:334-273-7000
Mailing Address - Fax:334-273-2386
Practice Address - Street 1:645 MCQUEEN SMITH RD N
Practice Address - Street 2:SUITE 109
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7268
Practice Address - Country:US
Practice Address - Phone:334-351-1000
Practice Address - Fax:334-358-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2007001584332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4248810003Medicare NSC