Provider Demographics
NPI:1619424371
Name:MONTOYA MEDICINE
Entity Type:Organization
Organization Name:MONTOYA MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:MONTOYA
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:424-832-3014
Mailing Address - Street 1:2001 S BARRINGTON AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5363
Mailing Address - Country:US
Mailing Address - Phone:424-832-3014
Mailing Address - Fax:
Practice Address - Street 1:2001 S BARRINGTON AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5363
Practice Address - Country:US
Practice Address - Phone:424-832-3014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15677171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty