Provider Demographics
NPI:1649488701
Name:MONTGOMERY, MARY GUIN (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GUIN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:GUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3805 GREENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4601
Mailing Address - Country:US
Mailing Address - Phone:205-333-2777
Mailing Address - Fax:
Practice Address - Street 1:701 UNIVERSITY BLVD E
Practice Address - Street 2:SUITE 809
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2086
Practice Address - Country:US
Practice Address - Phone:205-247-2934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered