Provider Demographics
NPI:1508821117
Name:MONTAGNAS SHOES INC
Entity Type:Organization
Organization Name:MONTAGNAS SHOES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MONTAGNA
Authorized Official - Suffix:JR
Authorized Official - Credentials:BOARD CERT PEDORTHIS
Authorized Official - Phone:757-490-2034
Mailing Address - Street 1:752 INDEPENDENCE BLVD
Mailing Address - Street 2:PEMBROKE MEADOWS SHOP CENTER
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455
Mailing Address - Country:US
Mailing Address - Phone:757-490-2034
Mailing Address - Fax:757-499-5465
Practice Address - Street 1:752 INDEPENDENCE BLVD
Practice Address - Street 2:MONTAGNAS SHOES
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-490-2034
Practice Address - Fax:757-499-5465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1181335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
16367OtherSENTARA
287425OtherANTHEM BCBS
0720990001Medicare ID - Type Unspecified