Provider Demographics
NPI:1740776954
Name:MONTANO WELLNESS LLC
Entity Type:Organization
Organization Name:MONTANO WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRENDAN
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-632-0144
Mailing Address - Street 1:160 WEST ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2441
Mailing Address - Country:US
Mailing Address - Phone:860-632-0144
Mailing Address - Fax:860-632-7882
Practice Address - Street 1:160 WEST ST STE 1A
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2441
Practice Address - Country:US
Practice Address - Phone:860-632-0144
Practice Address - Fax:860-632-7882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty