Provider Demographics
NPI:1154107951
Name:LITTLE RIVER PEDIATRICS INC
Entity type:Organization
Organization Name:LITTLE RIVER PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY BOGUS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:256-412-4743
Mailing Address - Street 1:140 ABBEY LN
Mailing Address - Street 2:
Mailing Address - City:KILLEN
Mailing Address - State:AL
Mailing Address - Zip Code:35645-8702
Mailing Address - Country:US
Mailing Address - Phone:256-412-4743
Mailing Address - Fax:
Practice Address - Street 1:314 WOODWARD AVE STE C
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-1540
Practice Address - Country:US
Practice Address - Phone:256-412-4743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty