Provider Demographics
NPI:1740215151
Name:MONTGOMERY, GEORGIA N (OWNER)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:N
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SAN PEDRO DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6722
Mailing Address - Country:US
Mailing Address - Phone:505-256-9587
Mailing Address - Fax:505-266-2484
Practice Address - Street 1:1020 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6722
Practice Address - Country:US
Practice Address - Phone:505-256-9587
Practice Address - Fax:505-266-2484
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75077311Medicaid