Individual
MR. TOM MONTGOMERY III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1929 BETTY JANE LN, MUSKOGEE, OK 74403-1581
(918) 683-9407
Mailing address
1929 BETTY JANE LN, MUSKOGEE, OK 74403-1581
(918) 683-9407
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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