Provider Demographics
NPI:1376542365
Name:MONTGOMERY, LARRY REWEL (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:REWEL
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-2667
Mailing Address - Country:US
Mailing Address - Phone:254-939-5801
Mailing Address - Fax:254-939-2229
Practice Address - Street 1:401 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-2667
Practice Address - Country:US
Practice Address - Phone:254-939-5801
Practice Address - Fax:254-939-2229
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-10-03
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
TXDC2818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G6130OtherBLUE CROSS BLUE SHIELD
TX8690B8Medicare PIN
TXT14875Medicare UPIN