Provider Demographics
NPI:1720468283
Name:MONTGOMERY, KINSEY (PHLEBOTOMY/LAB ASST)
Entity Type:Individual
Prefix:MR
First Name:KINSEY
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PHLEBOTOMY/LAB ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 PINES RD
Mailing Address - Street 2:SUITE 1200 D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3935
Mailing Address - Country:US
Mailing Address - Phone:318-626-5353
Mailing Address - Fax:318-626-5353
Practice Address - Street 1:7505 PINES RD
Practice Address - Street 2:SUITE 1200 D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3935
Practice Address - Country:US
Practice Address - Phone:318-626-5353
Practice Address - Fax:318-626-5353
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-31
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP.202263-LAB246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory