Provider Demographics
NPI:1124770870
Name:MONTENEGRO, MARCO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:MONTENEGRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 W SERENE AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6559
Mailing Address - Country:US
Mailing Address - Phone:702-515-9523
Mailing Address - Fax:
Practice Address - Street 1:2455 W SERENE AVE APT 202
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6559
Practice Address - Country:US
Practice Address - Phone:702-515-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV608-T28343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)