Provider Demographics
NPI:1467730952
Name:JACK C. MONTGOMERY VA MEDICAL CENTER
Entity Type:Organization
Organization Name:JACK C. MONTGOMERY VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF, VOLUNTARY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-577-3621
Mailing Address - Street 1:102 YORK VILLAGE DR
Mailing Address - Street 2:APT 1
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-4843
Mailing Address - Country:US
Mailing Address - Phone:918-616-4626
Mailing Address - Fax:
Practice Address - Street 1:102 YORK VILLAGE DR
Practice Address - Street 2:APT 1
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4843
Practice Address - Country:US
Practice Address - Phone:918-616-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable