1790021632 NPI number — MR. JERRY DWAYNE MONTGOMERY SLP

Table of content: MR. JERRY DWAYNE MONTGOMERY SLP (NPI 1790021632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790021632 NPI number — MR. JERRY DWAYNE MONTGOMERY SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTGOMERY
Provider First Name:
JERRY
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790021632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
631 S PARKHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REPUBLIC
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65738-2172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-773-6186
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
639 W CHESTNUT EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65802-3935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-523-7500
Provider Business Practice Location Address Fax Number:
417-523-7695
Provider Enumeration Date:
12/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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