Provider Demographics
NPI:1275160947
Name:MONTMORENCY, SAMUEL DRUCE
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DRUCE
Last Name:MONTMORENCY
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 1:12482 S RED ELM WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7193
Mailing Address - Country:US
Mailing Address - Phone:801-641-4872
Mailing Address - Fax:
Practice Address - Street 1:5126 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-5994
Practice Address - Country:US
Practice Address - Phone:801-213-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2019032895146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic