Provider Demographics
NPI:1205977428
Name:MONTFORD MEDICAL SERVICES
Entity type:Organization
Organization Name:MONTFORD MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEVESTER
Authorized Official - Last Name:MONTFORD
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:478-971-1299
Mailing Address - Street 1:PO BOX 2181
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31099-2181
Mailing Address - Country:US
Mailing Address - Phone:478-971-1299
Mailing Address - Fax:478-953-6879
Practice Address - Street 1:218 TRELLIS WALK
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31028-8510
Practice Address - Country:US
Practice Address - Phone:478-971-1299
Practice Address - Fax:478-953-6879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1238OtherLICENSE NUMBER
GA00546268AMedicaid
GA0575310001Medicare NSC