Basic Information
| Provider Information | |||||||||
| NPI: | 1114028305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTANA | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305295777 | ||||||||
| FaxNumber: | 5305295772 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960803954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302411473 | ||||||||
| FaxNumber: | 5305295772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT14685 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ135352 | 01 | CA | BLUE SHIELD GROUP NUMBER | OTHER | P00052571 | 01 | CA | RAIL ROAD MEDICARE PIN | OTHER | PT0146850 | 05 | CA | MEDICAID |