Provider Demographics
NPI:1730320946
Name:MONTGOMERY CLINIC LLC
Entity Type:Organization
Organization Name:MONTGOMERY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:I
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-354-9348
Mailing Address - Street 1:114 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5725
Mailing Address - Country:US
Mailing Address - Phone:318-354-9348
Mailing Address - Fax:318-354-9269
Practice Address - Street 1:641 ROWENA ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:LA
Practice Address - Zip Code:71454
Practice Address - Country:US
Practice Address - Phone:318-354-9348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022285207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty