Provider Demographics
NPI:1972844249
Name:MONTGOMERY, WALTER WILLIS
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:WILLIS
Last Name:MONTGOMERY
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 1:23701 E EAST FORK RD
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1477
Mailing Address - Country:US
Mailing Address - Phone:626-250-3290
Mailing Address - Fax:626-910-1380
Practice Address - Street 1:23701 E EAST FORK RD
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-1477
Practice Address - Country:US
Practice Address - Phone:626-250-3290
Practice Address - Fax:626-910-1380
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator