Provider Demographics
NPI:1780281303
Name:MONTGOMERY, CRYSTAL R
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:R
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-2665
Mailing Address - Country:US
Mailing Address - Phone:985-294-4169
Mailing Address - Fax:
Practice Address - Street 1:526 UNION AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-2665
Practice Address - Country:US
Practice Address - Phone:985-294-4169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care