Individual
MR. TOM MONTGOMERY III
Active
Individual
MR. TOM MONTGOMERY III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Taxonomy
Speciality
Code
Description
License number
State
376G00000X
Nursing Home Administrator
Primary
2286
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200106120A
—
OK
01
—
375174
MEDICARE PROVIDER ENROLLMENT
OK
Enumeration date
01/15/2015
Last updated
01/15/2015
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