Provider Demographics
NPI:1184018814
Name:MONTGOMERY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SOUTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3277
Mailing Address - Country:US
Mailing Address - Phone:712-292-9967
Mailing Address - Fax:
Practice Address - Street 1:621 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3277
Practice Address - Country:US
Practice Address - Phone:712-292-9967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer