Provider Demographics
NPI:1760126643
Name:MCKENZIE, MONTAVIOUS T
Entity Type:Individual
Prefix:
First Name:MONTAVIOUS
Middle Name:T
Last Name:MCKENZIE
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 1:1 MAGNOLIA CT
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6764
Mailing Address - Country:US
Mailing Address - Phone:229-502-9753
Mailing Address - Fax:
Practice Address - Street 1:1 MAGNOLIA CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6764
Practice Address - Country:US
Practice Address - Phone:229-502-9753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program