Provider Demographics
NPI:1790094241
Name:CHAUNCY MONTGOMERY
Entity Type:Organization
Organization Name:CHAUNCY MONTGOMERY
Other - Org Name:THE SECRET PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAUNCY
Authorized Official - Middle Name:DENETTE
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-347-2399
Mailing Address - Street 1:1114 JR ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-9462
Mailing Address - Country:US
Mailing Address - Phone:912-537-4143
Mailing Address - Fax:912-537-4143
Practice Address - Street 1:1114 JR ROLLINS RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-9462
Practice Address - Country:US
Practice Address - Phone:912-537-4143
Practice Address - Fax:912-537-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care