Provider Demographics
NPI:1306395363
Name:MONTGOMERY, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1466 BEACH AVE APT 12A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-3622
Mailing Address - Country:US
Mailing Address - Phone:347-431-2880
Mailing Address - Fax:
Practice Address - Street 1:1500 NOBLE AVE
Practice Address - Street 2:APT 10C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-3107
Practice Address - Country:US
Practice Address - Phone:347-431-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY814016687OtherDURABLE MEDICAL EQUIPMENT SUPPLIER