Provider Demographics
NPI:1528418399
Name:THORNTON, MONTRELL
Entity Type:Individual
Prefix:
First Name:MONTRELL
Middle Name:
Last Name:THORNTON
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 1:14812 STRATFORD CT
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-1962
Mailing Address - Country:US
Mailing Address - Phone:314-322-4656
Mailing Address - Fax:
Practice Address - Street 1:111 W PORT PLZ FL 6
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3011
Practice Address - Country:US
Practice Address - Phone:314-322-4656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO160510132512859253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care