Provider Demographics
NPI:1457315202
Name:MONTGOMERY, ANDRE LAMONT (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:LAMONT
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 1:684 AVON BELDEN ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-4111
Mailing Address - Country:US
Mailing Address - Phone:440-930-5537
Mailing Address - Fax:440-930-5237
Practice Address - Street 1:684 AVON BELDEN RD
Practice Address - Street 2:SUITE B
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-4110
Practice Address - Country:US
Practice Address - Phone:440-930-5537
Practice Address - Fax:440-930-5237
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3302111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2324167Medicaid
OHU90062Medicare UPIN
OH2324167Medicaid