Basic Information
| Provider Information | |||||||||
| NPI: | 1871799098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | YVITA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTGOMERY | ||||||||
| OtherFirstName: | YVITA | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 757 W SEPULVEDA ST UNIT B | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907311941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392689 | ||||||||
| FaxNumber: | 2133891987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 WILSHIRE BLVD | ||||||||
| Address2: | 7 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392689 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.